TN 67 (07-15)

NL 00703.106 Notice to Overpaid Person in Non-pay Status — Refund Requested

Document Identifier for Aurora: E3106

DPS Notice: Notice of Overpaid Person in Pay/Nonpay Title 2

A. Exhibit letter

We paid you $*F1 more in *F2 benefits than you were due.*F3 (E3106.1)

How To Pay Us Back

Please refund this overpayment within 30 days. Make your check

or money order payable to "Social Security Administration."

Include the claim number shown above on the check or money

order, and send it to us in the enclosed envelope. If you

cannot refund the full $*F1 now, please submit (a) a partial

payment; (b) an explanation of your financial situation; and (c)

a definite plan to repay the balance. (3106E)

*F2

(Use the UTI below only when the beneficiary is receiving other program benefits)

Instead of sending us a refund, we can withhold part or all of

your overpayment from your *F1. This method of repayment is

voluntary. You may stop the withholding at any time. We will

not change your *F2 if you do not choose this method of

repayment. If you want us to withhold the overpayment from your

*F3, please get in touch with us right away. (3106A)

If You Think You Should Not Have To Pay Us Back

You may not have to pay us back. Sometimes we can waive the

collection of an overpayment, which means you will not have to

pay us back. For us to waive the collection of your

overpayment, two things must be true.

  • It was not your fault that you got too much Social Security

    money.

    AND

  • Paying us back would mean you cannot pay your bills for

    food, clothing, housing, medical care, or other necessary

    expenses, or it would be unfair for some other reason.

    If you think these are true about you, contact any Social Security office 1.

    You can ask for waiver at any time by filling out the waiver form. The form number is SSA-632-BK. We will not collect the

    overpayment while we decide if we can waive collection.



    You may need to show us proof of your monthly income, expenses,

    and assets. Examples are pay stubs, pension records, rent

    receipts, utility bills and bank statements. (3106B)

If You Disagree With The Decision

If you disagree with the decision, you have the right to appeal.

A person who did not make the first decision will decide your

case. We will review your case again and consider any new facts

you have.

  • You have 60 days to ask for an appeal. If you ask in the

    next 30 days, you will not have to pay us back until we

    decide your case.

  • Both the 30- and 60-day periods start the day after you

    receive this letter. We assume you got this letter 5 days

    after the date on it, unless you show us that you did not

    get it within the 5-day period.

  • You must have a good reason if you wait more than 60 days to

    ask for an appeal.

    You have to ask for an appeal in writing. We will ask you

    to sign a form called, "Request For Reconsideration." The

    form number is SSA-561-U2. To get this form, contact one of

    our offices. We can help you fill out the form.

    We are enclosing a pamphlet called "Important Information About Your Appeal and Waiver Rights." Please be sure to read it.

    Even if you do not want to request reconsideration or waiver,

    call us at 1-800-772-1213 if you have any questions. (3106C Domestic)

Or

If you disagree with the decision, you have the right to appeal.

A person who did not make the first decision will decide your

case. We will review your case again and consider any new facts

you have.

  • You have 60 days to ask for an appeal. If you ask in the

    next 30 days, you will not have to pay us back until we decide your case.

  • Both the 30- and 60-day periods start the day after you

    receive this letter.

  • You must have a good reason if you wait more than 60 days to

    ask for an appeal.

  • You have to ask for an appeal in writing.

We are enclosing a pamphlet called "Important Information About

Your Appeal and Waiver Rights." Please be sure to read it.



Even if you do not want to request reconsideration or waiver, please call, write or visit (1) if you have any questions. Please take this letter with you if you do visit an office. (3106D Foreign)

If You Want Help With Your Appeal2 (REPC01)

You may choose to have a representative help you. We will work

with this person just as we would work with you. If you decide

to have a representative, you should find one quickly so that

person can start preparing your case.

Many representatives charge a fee only if you receive benefits.

Others may represent you for free. Usually, your representative

may not charge a fee unless we approve it. Your local Social

Security office can give you a list of groups that can help you

find a representative.

If you get a representative, you or that person must notify us in

writing. You may use our Form SSA-1696 "Appointment of

Representative." Any local Social Security office can give you

this form. (REP002)

Suspect Social Security Fraud?

Please visit http://oig.ssa.gov/r or call the Inspector

General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Any Questions

We invite you to visit our website at www.socialsecurity.gov on

the Internet to find general information about Social Security.

If you have any specific questions, you may call us toll-free at

1-800-772-1213, or call your local Social Security office at

1-*F3- *F4- *F5. We can answer most questions over the phone.

If you are deaf or hard of hearing, you may call our TTY number,

1-800-325-0778. You can also write or visit any Social Security

office. The office that serves your area is located at:

*F6

*F7

*F8

*F9 *F10- *F11

If you do call or visit an office, please have this letter with

you. It will help us answer your questions. Also, if you plan

to visit an office, you may call ahead to make an appointment.

This will help us serve you more quickly when you arrive at the

office. (CTDO Domestic)

 

Enclosures (2):

SSA-3105

Refund envelope

B. Requesting instructions

The person who determines the overpayment (generally the benefit authorizer) is responsible for requesting this notice and providing the appropriate fill-ins.

If the overpayment computation is too complex for a simple narrative explanation, use a chart such as the following:

Month/Year

Amount Paid

Amount Payable

Difference

01/84

 

 

 

02/84

 

 

 

etc.

 

 

 

Total

 

 

 

E3106.1 Fill-Ins

*F1-1 Amount of overpayment

*F2-1 Social Security

*F2-2 Black Lung

*F3-1 Explanation of Overpayment-dictated text

Use UTI 3106A if the liable individual is receiving other program benefits (e.g., a person liable for repayment of a title II overpayment receives Black Lung or title XVI payments).

3106A Fill-Ins:

*F1-1 Type of Benefit

*F2-1 Type of Benefit

*F3-1 Type of Benefit

Use 3106D if the person is outside the U.S.

3106D Fill-Ins:

Use a fill-in from paragraph 3901D in NL 00703.005E.

3106E Fill-Ins:

*F1-1 Amount of overpayment

*F2-1 3100FC

Use 3100FC if the person is outside the U.S.

 

 

 

1 If the person lives outside the U.S., substitute a fill-in from paragraph 3901D in NL 00703.005 E.

2 If the person lives outside the U.S. or has an attorney, omit this paragraph.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900703106
NL 00703.106 - Notice to Overpaid Person in Non-pay Status — Refund Requested - 08/22/2016
Batch run: 01/30/2024
Rev:08/22/2016