TN 30 (03-96)
NL 00703.107 Notice to Overpaid Person In Nonpay Status — Refund Requested —Alien Tax Withholding Involved
Document Identifier for Word Processor: E3107
A. Exhibit Letter
We sent you $ (1) more in Social Security benefits than we should have.
How To Pay Us Back
|3107B||You should refund this overpayment within 30 days. Please make your check or money order payable to “Social Security Administration” and send it to us in the enclosed envelope. Always include your claim number (as shown above) on the check or money order. If you cannot refund the $ (1) now, you should give us: (a) a partial payment; (b) an explanation of your assets and income and expenses; and (c) a definite plan for repaying the rest of the money.|
| ||Please send your check or money order in United States currency or in local currency equal to the United States dollars. When you pay us in local currency, we use the exchange rate in effect at the time we get your payment. If this causes a difference between the amount you pay us and the amount you owe us, we will let you know. If you cannot mail your payment directly to us, please go to the nearest United States Embassy or consulate for help in making the refund.|
|3106A (Optional)|| |
If You Think You Should Not Have To Pay Us Back
If You Disagree With The Decision
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.
Paragraph 3106A is used if cross-program adjustment is possible. Use 3107B, 3106B and 3106D in all cases. Refer to NL 00703.106 for 3106A, 3106B and 3106D text and fill-ins.
amount of the overpayment (not including taxes withheld)
narrative overpayment explanation - A chart may be included following the explanation.
|3107B||(1) amount of the overpayment (not including tax withholding)|
C. Typing Instructions
Use Form SSA-L2000-C2 (Universal Notice) and follow notice standards. Information for this notice will be shown on Form SSA-573.