We sent you $ (1) more in Social Security benefits for (2) than we should have.

(3) .

As representative payee, you are personally liable for repayment unless you used the overpaid funds for the benefit of (4) and the overpayment was made through no fault of your own.

 

How To Pay Us Back

3107B
3106A (Optional)

 

If You Think You Should Not Have To Pay Us Back

3106B

 

If You Disagree With the Decision

3112B

 

Enclosures (2):

Form SSA-3105

Refund envelope

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

• •

  Use 3106A if cross-program adjustment is possible.

• •

  Use 3107B, 3106B and 3112B in all cases.

Refer to NL 00703.107 for 3107B text and fill-ins. Refer NL 00703.106 for 3106A and B text and to NL 00703.112 for 3112B text.

 

Fill-ins

1. (1) 

   amount of the overpayment (not including taxes withheld)

2. (2) 

   name(s) of beneficiary(ies)

3. (3) 

   narrative overpayment explanation - A chart may be included following the explanation.

4. (4) 

   name(s) of beneficiary(ies)

Use Form SSA-L2000-C2 (Universal Notice) and follow notice standards. Information for this notice will be shown on Form SSA-573.