TN 71 (04-16)

NL 00703.165 Waiver Notice for Requesting Authorization to Access Financial Information

Document Identifier for Aurora: E4023

A. Exhibit letter

This letter contains important information about *F1 waiver request. Please read it carefully. If there is anything you do not understand, please get in touch with us right away.


The law requires us to get permission from *F2 for us to obtain *F3 bank records. We may need to review these bank records before we can make a decision on *F4 waiver request. (LIS033)

What We Are Asking You To Do (INFC58)

We are requesting permission to obtain *F1 bank records because, if we consider *F2 ability to pay us back when making a waiver decision, we look at all available resources. We are asking *F3 to: (WAV040)

  • Read the enclosed form SSA-4641-F4, Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records. (WAV032)

  • Read and complete the enclosed form SSA-632-BK, Request for Waiver of Overpayment Recovery or Change Repayment Rate. (OPTIONAL-WAV033)

  • However, if you are the parent of a minor child or the legal guardian of the person who was overpaid, you must sign the form(s) for them. (OPTIONAL-WAV034)

  • Sign and date the highlighted sections of the enclosed form(s) and return the form(s) to us in the enclosed envelope. (WAV035)

What It Means To Give Permission To Contact Financial Institutions (SSIC11)

We may use the bank records we obtain to decide if we can waive the overpayment. Once *F1 permission for us to obtain bank records, we may contact any financial institution to obtain records until one of the following occurs:

  1. We are notified in writing that *F2 canceled *F3 permission; or

  2. We make a final decision on the waiver request. (WAV036)

If We Do Not Receive Permission (INFC59)

If we do not receive permission to obtain bank records or if *F1 permission, we may not approve the waiver request. (WAV037)

If We Don't Hear From You (CAPC40)

If we do not receive a response to this request within 30 days from the date of this letter, we may not approve the waiver request. (WAV038)

If We Do Not Approve The Waiver Request (WAVC07)

If we do not approve the waiver request, we will send another letter informing you that you have the right to meet with us before we decide if *F1 must pay us back the overpayment. (WAV039)

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 questions, you should contact *F1. You may also write to the Social Security Administration, P.O. Box 17769 Baltimore, Maryland 21235, U.S.A. Please be sure to include your claim number if you do write. However, if you visit an office, please take this letter. It will help the people there answer your questions. (3901D Foreign)

Or

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:

SSA-4641

SSA-632-BK (only when optional UTI WAV033 is selected)

Return Envelope (BRM)

B. Requesting instructions

The person who handles the initial inquiry about the waiver of overpayment is responsible for requesting this notice and providing the appropriate fill-ins.

You must consider the following UTIs if using the Special Notice Option (SNO):

  • UTI SNO015

  • UTI SNO016

  • UTI SNO017

For more information about SNO notices please see NL 01001.000.

LIS033 Fill-Ins

*F1-1 your

*F1-2 Client Name (possessive)

*F2-1 you

*F2-2 him

*F2-3 her

*F2-4 Client name

*F3-1 your

*F3-2 his

*F3-3 her

*F3-4 Client name (possessive)

*F4-1 your

*F4-2 his

*F4-3 her

*F4-4 Client name (possessive)

WAV040 Fill-Ins</