You offered to settle (1) $ (2) (3) overpayment by paying us $ (4) . We are writing to tell you that we cannot accept your offer. This means that (5) to pay back the full amount of the overpayment.

 

The Reason For Our Decision

We looked at the following things before we decided if we could accept your offer.

• •

  We looked at how the overpayment happened.

• •

  We looked at (6) ability to pay us back.

  And

• •

  We looked at how close your offer was to the full amount of the overpayment.

After we looked at these things, we decided that we cannot accept the $ (7) offer you made. However, we might accept an offer that is closer to the amount (8) us. If you want to make another offer, contact (9) .

 

How To Pay Us Back

If you do not want to make another compromise offer, there are two ways you can pay back the full amount of (10) overpayment.

• •

  You can send us a check or money order for the full amount of the overpayment. Make your check or money order out to the Social Security Administration. Be sure to put (11) , (12) on it. Please use the enclosed envelope to mail your check or money order to us.

  OR

• •

  If you can not send us the full amount now, send as much as you can. Then contact (13) . You can pay the rest of the money (14) by making monthly payments.

If you cannot pay us in full, please contact us by (15) . You will need to tell us how you plan to pay us back.

3100FC (Foreign Cases Only):

 

If We Do Not Hear From You (Domestic Cases Only)

If you do not pay us or get in touch with us about this overpayment by (16) , we will consider sending (17) case to the Department of Justice.

If we do this, the Department of Justice might take you to court to collect the overpayment. If that happens and the court decides against you, you might have to pay both the overpayment and court costs.

 

If You Have Any Questions

3901C - Domestic

3901D - Foreign

 

Enclosure:

Refund Envelope

The recovery reviewer is responsible for requesting this notice and providing the appropriate fill-ins for SSA or BL cases.

See NL 00703.100 for 3100FC and NL 00703.005E for 3901 C and D text. Do not include “If We Do Not Hear From You” paragraph in foreign cases.

 

Fill-ins:

1. (1) 

   your, beneficiary/recipient's full name—possessive

2. (2) 

   amount of overpayment

3. (3) 

   Social Security, Supplemental Security Income, Black Lung

4. (4) 

   compromise offer amount

5. (5) 

   you have, he has, she has

6. (6) 

   your, beneficiary/recipient's first name—possessive, if child. If adult use “Mr.” or “Ms.” last name—possessive.

7. (7) 

   compromise offer amount

8. (8) 

   you owe, beneficiary/recipient's first name owes, if child. If adult, “Mr.” or “Ms.” last name owes

9. (9) 

   In domestic cases:

   any Social Security office

   In foreign cases:

   the office shown later in this letter

10. (10) 

    your, recipient/beneficiary's first name—possessive, if child. If adult, “Mr.” or “Ms.” last name—possessive.

11. (11) 

    your claim number, his claim number, her claim number (Title II), your Social Security number, his Social Security number, her Social Security number (Title XVI)

12. (12) 

    Social Security number and symbol of the record on which the overpayment exists

13. (13) 

    In domestic cases use:

    any Social Security office

    In foreign cases use:

    us

14. (14) 

    you owe, he owes, she owes

15. (15) 

    Month, day and year by which payment is expected in the format, June 30, 1986

16. (16) 

    contact date in the format of June 30, 1986

17. (17) 

    your, beneficiary/recipient's first name—possessive, if child. If adult “Mr.” or “Ms.” last name—possessive.

Use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards for cases processed in the PC. Because the requested fill-ins and paragraph may vary according to the different situations, follow the requester's instructions carefully. There is a refund envelope enclosure. Include a “refund envelope” with the letter and type the claim number on the inside of the envelope below the flap. Place the envelope lengthwise on the left-hand side of the notice and staple in the upper left-hand corner.