When you receive (1) benefits on (2) Social Security record, you were overpaid $ (3) . In a letter we sent to you earlier, we told you how this overpayment happened and
about your right to question our decision about the overpayment.
You still owe us $ (4) . We are writing to tell you how to pay this money back. This letter will also tell
you what to do if you think the overpayment was not your fault or if you cannot afford
to pay us back.
You or your representative have the right to request a determination concerning the
need to recover the overpayment. This is called waiver. You may request waiver at
any time. A request for waiver will be approved if both of the following are true:
The overpayment is not your fault in any way, and
You could not meet your necessary living expenses if we recovered the overpayment,
or recovery would be unfair for some other reason.
If you request waiver, we may need a statement of your assets and monthly income and
We will notify you in writing of our determination.
If you request waiver within 30 days of the date of this notice, we will not take
any action to recover the overpayment unless waiver is denied after you have had opportunity
for a personal conference.
If you request waiver after 30 days, the action to recover the overpayment as indicated
above will be stopped and any payment withheld on or after the date of your request
will be paid back to you. We will not resume any recovery action unless you are denied
waiver after you have had an opportunity for a personal conference.
If you request waiver and after reviewing your request we cannot approve it, we will
notify you in writing of our reasons. (5) A personal conference with a Social Security employee will then be scheduled for
you so that you can explain why you do not believe your waiver request should be denied.
More information about the personal conference is given in the notice if we cannot
waive recovery of your overpayment.
If you disagree with the waiver decision you have other appeal rights. These appeal
rights will also be explained in detail in the waiver determination notice.
If you request waiver, you will be asked when you contact a Social Security office
to complete Form SSA-632-BK (Request for Waiver of Overpayment Recovery or Change
in Repayment Rate). Even if you do not want to request waiver, please call, write,
or visit any Social Security office1 if you cannot afford the planned withholding of your payment. Please take this letter
with you if you do visit an office. Unless we hear from you within 30 days, we will
withhold your payment as shown above.
If You Have Any Questions
3901C - Domestic
3901D - Foreign
1 If the person lives outside the U.S., substitute a fill-in from paragraph 3901D in