When (1) received (2) benefits on (3) Social Security record, (4) was overpaid
$ (5) . In a letter we sent earlier, we told you (6) how this overpayment happened and about (7) right to question our decision about the overpayment. (8) still owes us $ (9) from this old overpayment. This is in addition to the $ (10) overpayment on (11) own Social Security record. The total amount (12) owes us in $ (13) .
We are writing to tell you how we pay back the old overpayment. This letter will also
tell you what to do if you think the overpayment was not (14) fault or if (15) cannot afford to pay us back.
You 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 (16) fault in any way, and
(17) could not meet (18) 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 (19) assets and monthly income and expenses.
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 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. (20) 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 (21) cannot afford the planned withholding of (22) payment. Please take this letter with you if you do visit an office. Unless we hear
from you within 30 days, we will withhold (23) 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