TN 33 (07-17)

GN 02201.010 SSA-3105 Processing Instructions

A. Description of the SSA-3105

We enclose form SSA-3105, “Important Information about Your Appeal, Waiver Rights, and Repayment Options,” with all Title II initial overpayment notices. This form gives overpaid individuals additional information regarding their reconsideration and waiver rights. The individual can use this form to request a repayment option, an explanation of the overpayment, waiver of recovery, or reconsideration of the overpayment determination by checking the appropriate box and returning the form.

You can view a copy of the SSA-3105 at OS 15010.725 or via inForms at http://inform.ssahost.ba.ssa.gov/libraryFormDetails.cfm?recordID=SSA-3105.

B. FO initial steps for processing the completed SSA-3105

The overpaid individual may send the completed SSA-3105 to the processing center (PC) or to the field office (FO). The FO should direct the returned form to the claims specialist (CS), or equivalent. The technician should review and process the request accordingly, or route it to the appropriate component. Take the following initial actions when you receive the form:

  1. Obtain a master beneficiary record (MBR) to determine if we stopped collection activity.

  2. Review the amount of overpayment and process the overpaid individual’s request on the returned form based on the instructions in GN 02201.010C in this section.

  3. Stop collection activity (if appropriate) using the Protest/Stop Recovery Request (FO) (DRPF) screen in DMS (see MSOM DMS 006.019) based on the overpaid individual’s request.

  4. Document your action(s) on the Remarks screen in DMS; include the date of the SSA-3105 and a summary of the individual’s request. For example, “Received SSA-3105 dated 05/05/16 from Jessica James HA requesting installment payments for $50 per month.”

C. FO processing instructions

Review the overpaid individual’s responses on the form and take the appropriate action.

1. Box 1 (reconsideration request)

The first box is a reconsideration request.

  • Input protest reason 4 for recon fact/amount via the DRPF screen in DMS to stop collection activity (if applicable);

  • Mail form SSA-561-U2 to the overpaid individual with the appropriate cover notice and a return envelope addressed to the PC of jurisdiction;

  • Document your action(s) on the Remarks screen in DMS; include a remark regarding the good cause determination if applicable. For example, “Received SSA-3105 dated 05/05/16 from Jessica James HA requesting reconsideration. Mailed form SSA-561-U2 and notice 05/08/16. –Luke Brown, FO AAA;”

  • Transfer jurisdiction to the appropriate PC via the WMS Debt Management Function Selection (DMFS) screen in DMS (see DMSWMS 002.003); and

  • Fax the SSA-3105 to the servicing PC via Paperless fax.

For more information regarding processing the overpayment reconsideration request, see GN 02201.025B.

2. Box 2 (waiver request)

The second box is a waiver request.

  1. If the overpayment is $1,000 or less and the request meets the requirements in GN 02250.350, take the following actions

    • Input protest reason 2 for informal waiver via the DRPF screen in DMS (if applicable);

    • Process the request under the $1,000 administrative waiver tolerance provision via GN 02250.350; and

    • Fax the SSA-3105 and any additional documentation into NDRed.

  2. If the overpayment amount is over $1,000, take the following actions:

    • Input protest reason 2 for informal waiver via the DRPF screen in DMS to stop collection activity (if applicable) (see GN 02201.021);

    • Mail forms SSA-632-BK, SSA-4641, and a waiver cover notice with a return envelope addressed to the FO of jurisdiction to the overpaid individual;

    • Document your action(s) on the Remarks screen in DMS. For example, “Received SSA-3105 dated 05/05/16 from Jessica James HA requesting waiver. Mailed forms SSA-632-BK and SSA-4641 with a waiver cover notice 05/08/16. –Luke Brown, FO AAA;”

    • Allow 30 days for receipt of the above forms and follow the instructions in GN 02201.021; and

    • Fax the SSA-3105 and any additional documentation into NDRed.

3. Box 3 (combined waiver and reconsideration request)

The third box is a combined waiver and reconsideration request.

  • Input protest reason 5 for waiver and recon fact/amount via the DRPF screen in the DMS to stop collection activity (if applicable);

  • Mail forms SSA-561-U2, SSA-632-BK, and SSA-4641 to the overpaid individual with the appropriate cover notice and return envelope addressed to the PC of jurisdiction;

  • Document your action(s) on the Remarks screen in DMS; include a remark regarding the good cause determination if applicable. For example, “Received SSA-3105 dated 05/05/16 from Jessica James HA requesting reconsideration and waiver. Mailed forms SSA-561-U2, SSA-632-BK, SSA-4641, and notice 05/08/16. –Luke Brown, FO AAA;” and

  • Fax the SSA-3105 to the servicing PC via Paperless fax.

NOTE: The PC must process the reconsideration request prior to the FO processing the waiver request.

4. Box 4 (partial withholding request)

The fourth box is a partial withholding request.

  1. If we can recover the overpayment within 12 months based on the requested withholding amount, take the following actions:

    • Input the request via the Establish Offset (Debtor) (DROA) screen in DMS (see MSOM DMS 006.015) following the guidelines in GN 02210.030B; and

    • Fax the SSA-3105 into NDRED.

  2. If recovery would take longer than 12 months, take the following actions:

    • Contact the overpaid individual to conduct financial development following guidelines in GN 02210.030B.; and

    • Fax the SSA-3105 into NDRED.

  3. If the overpaid individual did not provide a partial withholding amount, take the following actions:

    • Call him or her to establish a rate of recovery following the guidelines in GN 02210.030B.

    • Send a direct contact notice in the mail requesting the necessary information, if you are unable to contact the overpaid individual;

    • Resume normal collection activity effective with the Current Operating Month (COM), if you do not receive a response;

    • Document your actions and rationale via DMS Remarks; and

    • Fax the SSA-3105 into NDRed.

5. Box 5 (monthly installment request)

The fifth box is a monthly installment request. Input the requested installment amount on the Record Installment Agreement (DRIN) screen in DMS (see MSOM DMS 006.014). For more information regarding installment payments, see GN 02210.180.

  1. If the overpaid individual did not provide an installment amount, or he or she did not submit a payment with the request, take the following actions:

    • Contact him or her to establish an installment amount;

    • Follow the guidelines in GN 02210.180; and

    • Fax the SSA-3105 into NDRed.

  2. If direct contact is unsuccessful, take the following actions:

    • Resume collection activity (if applicable) effective COM via the applicable Record Installment Agreement (DRIN) screen or DROA screen in DMS;

    • Send a dictated notice explaining that we received form SSA-3105 but we were unsuccessful contacting him or her regarding the incomplete request;

    • Document your action(s) on the Remarks screen in DMS. For example, “Received SSA-3105 installment payment request dated 06/07/16 for Jessica James HA, the installment amount is missing on the form, and payment not included. Attempted to contact Ms. James but was unsuccessful. Resumed collection activity 07/10/16 and sent a notice to Ms. James. – Luke Brown, FO AAA;” and

    • Fax the SSA-3105 into NDRed.

    NOTE: Although the DRIN screen allows the technician to input an installment agreement for an individual that is in any ledger account file (LAF) S suspense status, only LAF S1-5, S7, and SH statuses will process correctly. All other suspense codes generate an exception (i.e., a computer error) in the recovery of Overpayments, Accounting and Reporting (ROAR) record. This is a systems processing limitation and the PC technician will have to use their office’s workaround procedures.

6. Box 6 (explanation request)

The sixth box is an explanation request.

  • Input protest reason 1 for explanation via the DRPF screen in DMS to stop collection activity (if applicable);

  • Follow the guidelines in GN 02201.017B.; and

  • Fax the SSA-3105 into NDRed

7. Box 7 (full refund request)

The seventh box is an offer of a full refund.

  1. If the overpaid individual encloses a remittance with the SSA-3105, process the request following the guidelines in GN 02403.006 and fax the SSA-3105 into NDRed.

  2. If the overpaid individual does not enclose a remittance with the SSA-3105, take the following actions:

    • Review the ROAR record to see if it shows that a full refund already closed out the debt (i.e. the overpayment balance is now $0.00). If so, take no action on the record and fax the SSA-3105 into NDRed; or

    • Review the ROAR record to see if it shows a remittance exception. If so, check Paperless Read Only Query System (Paperless ROQS) to see if an action is pending with the type of event levels (TOEL) of OPMT REMIT. If an action is pending, take no further action and fax the SSA-3105 into NDRed. If no action is pending, contact the servicing PC via Modernized Development Worksheet (MDW), request that they take the necessary actions to credit the remittance to the appropriate overpayment and fax the SSA-3105 into NDRed.

  3. If there is no evidence of a remittance, take the following actions:

    • Resume collection activity (if applicable) effective COM via the applicable DRIN or DROA screen in DMS;

    • Send the overpaid individual a dictated notice stating that, since we did not receive a refund with their SSA-3105, we are starting recovery of the overpayment;

    • Document your action(s) on the Remarks screen in DMS. For example, “Received SSA-3105 refund request dated 06/07/16 for Jessica James HA and payment not included. Resumed collection activity 07/10/16 and sent a notice to Ms. James. – Luke Brown, FO AAA;” and

    • Fax the SSA-3105 into NDRed.

8. Box 8 (other)

The eighth box is for other.

  1. If the overpaid individual checked this box and provided an explanation on a separate sheet of paper, process accordingly, and fax the SSA-3105 with documentation into NDRed

  2. If an overpaid individual did not enclose an explanation, take the following actions:

    • Call the overpaid individual and ask what he or she is requesting;

    • Process the request accordingly;

    • Document your action(s) on the Remarks screen in DMS. For example, “Received SSA-3105 dated 06/07/16 for Jessica James HA, “other” box was checked. Called Ms. James and she requested partial withholding of $50 for 12 months. Action taken 06/10/16 and sent a notice to Ms. James. – Luke Brown, FO AAA;” and

    • Fax the SSA-3105 into NDRed.

  3. If direct contact is unsuccessful, take the following actions:

    • Resume collection activity (if applicable) effective COM via the applicable DRIN or DROA screen in DMS ;

    • Send a dictated notice explaining that we received form SSA-3105 but we were unsuccessful contacting him or her regarding the incomplete request;

    • Document your action(s) on the Remarks screen in DMS. For example, “Received SSA-3105 “other” request dated 06/07/16 for Jessica James HA and an explanation was not included. Attempted to contact Ms. James but was unsuccessful. Resumed collection activity 07/10/16 and sent a notice to Ms. James. – Luke Brown, FO AAA;” and

    • Fax the SSA-3105 into NDRed.

9. Multiple boxes checked

  1. If the overpaid individual checked multiple boxes, contact him or her and ask for clarification and process accordingly.

  2. If direct contact is unsuccessful, process the request(s) in the following order below as applicable, send a notice that applies to the action you took, and fax the SSA-3105 into NDRed:

    • Partial recovery/installment,

    • Explanation,

    • Reconsideration, or

    • Waiver.

10. No boxes are checked

If the overpaid individual did not check any boxes, assume the overpaid individual is requesting an explanation of the overpayment and follow the instructions in GN 02201.010C.6 in this section.

D. PC initial steps for processing the completed SSA-3105

The overpaid individual may send the completed SSA-3105 to the PC or to the FO. The PC modules should direct the returned form to the benefit authorizer (BA), or the equivalent, for processing. The technician should review and process the request accordingly, or route it to the appropriate component. Take the following initial actions when you receive the form:

  1. Obtain a master beneficiary record (MBR) to determine if we stopped collection activity.

  2. Review the amount of overpayment and process the overpaid individual’s request on the returned form based on the instructions in GN 02201.010E and GN 02201.010F in this section.

  3. Stop collection activity (if applicable) using the Protest/Stop Recovery Request (PC) (DRPR) screen in DMS (see MSOM DMS 006.003) based on the overpaid individual’s request.

  4. Document your action(s) on the Remarks screen in DMS; include the date of the SSA-3105 and a summary of the individual’s request. For example, “Received SSA-3105 dated 05/05/16 from Jessica James HA requesting installment payments for $50 per month.”

E. PC instructions for cross program recovery (CPR) cases

If you receive an SSA-3105 and there is a ROAR record where the type of overpayment is PUB ASSIST with a trust fund of “7,” this is a CPR case. We are recovering the individual’s Title XVI overpayment from his or her Title II record. Take the following actions:

  • Contact the FO via the Modernized Development Worksheet (MDW) (or the equivalent) for them to take action on the request following the guidelines in SI 02220.020D; and

  • Document your actions on the Remarks screen in DMS. For example, “Received SSA-3105 dated 02/06/17 from Jessica James requesting a different rate of withholding, cross-program recovery involved. Forwarding this request to FO AAA and faxed material into NDRed. – Luke Brown, BA Mod 1;” and

  • Fax the SSA-3105 into the Non-Disability Repository for Evidentiary Documents (NDRed).

F. PC processing instructions

Review the overpaid individual’s responses on the form and take the appropriate action.

1. Box 1 (reconsideration request)

The first box is a reconsideration request.

  1. If the overpaid individual did not provide sufficient information to process the reconsideration request, take the following actions.

    • Input protest reason 4 for recon fact/amount via the DRPR screen in DMS to stop collection activity (if applicable);

    • Mail form SSA-561-U2 to the overpaid individual with the appropriate cover notice and return envelope addressed to the PC of jurisdiction; and

    • Document your action(s) on the Remarks screen in DMS; include a remark regarding the good cause determination if applicable. For example, “Received SSA-3105 dated 05/05/16 from Jessica James HA requesting reconsideration. Mailed form SSA-561-U2 and notice 05/08/16. –Luke Brown, CA Mod 1;” and

    • Follow the overpayment reconsideration instructions in GN 02201.025 upon receipt of the completed form(s).

  2. If you do not receive the completed form(s) when the ROAR diary matures, take the following actions:

    • Resume collection activity (if applicable) effective COM via the applicable DRIN or DROA screen in DMS;

    • Send a dictated notice explaining that we received form SSA-3105 but we were unsuccessful contacting him or her regarding the incomplete request; and

    • Document your action(s) on the Remarks screen in DMS. For example, “Received SSA-3105 dated 05/05/16 from Jessica James requesting reconsideration. Ms. James did not return the completed SSA-561-U2 we mailed to her on 05/08/16. Resumed collection activity 07/10/16 and sent a notice to Ms. James. – Luke Brown, Mod 1.”

  3. If the overpaid individual provided sufficient information to process the reconsideration request, take the following actions:

    • Input protest reason 4 for recon fact/amount via the DRPR screen in DMS to stop collection activity (if applicable); and

    • Follow the overpayment reconsideration instructions in GN 02201.025.

    For more information regarding processing the overpayment reconsideration request, see GN 02201.025C and GN 03102.200.

2. Box 2 (waiver request)

The second box is a waiver request.

  1. If the overpayment is $1,000 or less and the request meets the requirements in GN 02250.350, take the following actions:

    • Input protest reason 2 for informal waiver via the DRPR screen in DMS (if applicable); and

    • Process the request under the $1,000 administrative waiver tolerance provision.

  2. If the overpayment amount is over $1,000, take the following actions:

    • Input protest reason 2 for informal waiver via the DRPR screen in DMS to stop collection activity (if applicable) (see GN 02201.023 and SM 00610.751A);

    • Mail forms SSA-632-BK, SSA-4641, and a waiver cover notice with a return envelope addressed to the FO of jurisdiction to the overpaid individual;

    • Document your action(s) on the Remarks screen in DMS. For example, “Received SSA-3105 dated 05/05/16 from Jessica James HA requesting waiver. Mailed forms SSA-632-BK and SSA-4641 with a waiver cover notice 05/08/16. –Luke Brown, BA Mod 1”; and

    • Fax the SSA-3105 into NDRed.

      NOTE: Since Paperless takes 120 days to transfer the faxed documentation into the Claims File Records Management System (CFRMS), the PC must fax the documentation into NDRed so that the FO technician will be able to see the documentation in case the overpaid individual walks into the FO.

3. Box 3 (combined waiver and reconsideration request)

The third box is a combined waiver and reconsideration request.

  1. If the overpaid individual did not provide sufficient information to process the requests, take the following actions:

    • Input protest reason 5 for waiver and recon fact/amount via the DRPR screen in the DMS to stop collection activity (if applicable);

    • Mail forms SSA-561-U2, SSA-632-BK, and SSA-4641 to the overpaid individual with the appropriate cover notice and return envelope addressed to the PC of jurisdiction;

    • Document your action(s) on the Remarks screen in DMS (include a remark regarding the good cause determination if applicable). For example, “Received SSA-3105 dated 05/05/16 from Jessica James HA requesting reconsideration and waiver. Mailed forms SSA-561-U2, SSA-632-BK, SSA-4641, and notice 05/08/16. –Luke Brown, BA Mod 1;”

    • Fax the SSA-3105 into NDRed; and

    • Follow the overpayment reconsideration instructions in GN 02201.025 upon receipt of the completed form(s).

  2. If you do not receive the completed form(s) when the ROAR diary matures, take the following actions:

    • Resume collection activity (if applicable) effective COM via the applicable DRIN or DROA screen in DMS;

    • Send a dictated notice explaining that we received form SSA-3105 but we were unsuccessful contacting him or her regarding the incomplete request; and

    • Document your action(s) on the Remarks screen in DMS. For example, “Received SSA-3105 dated 05/05/16 from Jessica James requesting reconsideration and waiver. Ms. James did not return the completed forms we mailed to her on 05/08/16. Resumed collection activity 07/10/16 and sent a notice to Ms. James. – Luke Brown, Mod 1.”

  3. If the overpaid individual provided sufficient information to process the requests, take the following actions:

    • Input protest reason 5 for waiver and recon fact/amount via the DRPR screen in DMS to stop collection activity (if applicable); and

    • Follow the overpayment reconsideration instructions in GN 02201.025.

    NOTE: We must process the reconsideration request prior to processing the waiver request.

4. Box 4 (partial withholding request)

The fourth box is a partial withholding request.

  1. If we can recover the overpayment within 12 months based on the requested withholding amount, take the following actions:

    • Input the request via the Establish Offset (Debtor) (DROA) screen in DMS (see MSOM DMS 006.015); and

    • Follow the guidelines in GN 02210.030B.

  2. If recovery would take longer than 12 months:

    • Conduct financial development; and

    • Follow the guidelines in GN 02210.030B.

  3. If the overpaid individual does not indicate a rate of partial withholding:

  • Call the overpaid individual to establish a rate of recovery, following guidelines in GN 02210.030B;

  • Send a direct contact notice in the mail requesting the necessary information, if you are unable to contact the overpaid individual;

  • Resume normal collection activity effective COM, if you do not receive a response; and

  • Document your actions and rationale via DMS Remarks.

5. Box 5 (monthly installment request)

The fifth box is a monthly installment request. Input the requested installment amount on the Record Installment Agreement (DRIN) screen in DMS (see MSOM DMS 006.014). For more information regarding installment payments, see GN 02210.180.

  1. If the overpaid individual did not provide an installment amount, or he or she did not submit a payment with the request, take the following actions:

    • Contact him or her to establish an installment amount; and

    • Follow the guidelines in GN 02210.180.

  2. If direct contact is unsuccessful, take the following actions:

    • Resume collection activity (if applicable) effective COM via the applicable DRIN or DROA screen in DMS ;

    • Send a dictated notice explaining that we received form SSA-3105 but we were unsuccessful contacting him or her regarding the incomplete request; and

    • Document your action(s) on the Remarks screen in DMS. For example, “Received SSA-3105 installment payment request dated 06/07/16 for Jessica James HA, the installment amount is missing on the form, and payment not included. Attempted to contact Ms. James but was unsuccessful. Resumed collection activity 07/10/16 and sent a notice to Ms. James. – Luke Brown, Mod 1.”

    NOTE: Although the DRIN screen allows the technician to input an installment agreement for an individual that is in any LAF S suspense status, only LAF S1-5, S7, and SH statuses will process correctly. All other suspense codes generate an exception (i.e., a computer error) in ROAR. This is a systems processing limitation and you will have to use your office’s workaround procedures.

6. Box 6 (explanation request)

The sixth box is an explanation request.

  • Input protest reason 1 for explanation via the DRPR screen in DMS to stop collection activity (if applicable); and

  • Follow the instructions in GN 02201.017D.

7. Box 7 (full refund request)

The seventh box is an offer of a full refund.

  1. If the overpaid individual encloses a remittance with the SSA-3105, follow your local procedures to process the remittance.

  2. If the overpaid individual does not enclose a remittance with the SSA-3105, take the following actions:

    • Review the ROAR record to see if it shows that a full refund already closed out the debt (i.e. the overpayment balance is now $0.00) and if so, take no action on the record; or

    • Review the ROAR record to see if it shows a remittance exception and if so, take the necessary actions to credit the remittance to the appropriate overpayment following the instructions in SM 00610.299.

  3. If there is no evidence of a remittance, take the following actions:

    • Resume collection activity (if applicable) effective COM via the applicable DRIN or DROA screen in DMS;

    • Send the overpaid individual a dictated notice stating that, since we did not receive a refund, we are starting recovery of the overpayment; and

    • Document your action(s) on the Remarks screen in DMS. For example, “Received SSA-3105 refund request dated 06/07/16 for Jessica James HA and payment not included. Resumed collection activity 07/10/16 and sent a notice to Ms. James. – Luke Brown, BA Mod 1.”

8. Box 8 (other)

The eighth box is for other.

  1. If the overpaid individual checked this box and provided an explanation on a separate sheet of paper, process accordingly.

  2. If an overpaid individual did not enclose an explanation, take the following actions:

    • Call the overpaid individual and ask what he or she is requesting;

    • Process the request accordingly; and

    • Document your action(s) on the Remarks screen in DMS. For example, “Received SSA-3105 dated 06/07/16 for Jessica James HA, “other” box was checked. Called Ms. James and she requested partial withholding of $50 for 12 months. Action taken 06/10/16 and sent a notice to Ms. James. – Luke Brown, BA Mod 1.”

  3. If direct contact is unsuccessful, take the following actions:

    • Resume collection activity effective COM via the applicable DRIN or DROA screen in DMS;

    • Send a dictated notice explaining that we receive