We are writing to let you know that you will have to return $ (1) of the (2) money we sent you as representative payee for the individual(s) shown on the enclosed
list. We determined that you did not use this money as you agreed. For that reason,
you must pay us back. The following gives you more information about our determination.
Optional – use if previously advised of misused funds
You were previously advised that you owed $(3) because you did not use the money for
the individuals shown on the attached list as you agreed. Because you failed to return
this money, we are allowed to collect this money from you.
How We Reached Our Decision
How To Pay Us Back
Send us a check or money order for the full amount you owe us. Make your check or
money order payable to the Social Security Administration and attach a copy of the
enclosed list of the affected beneficiaries. Always include your claim number (as
shown above) on your check or money order. Be sure to return both the check and a
copy of the list of individuals in the enclosed envelope.
If you do not pay us back, the law allows us to use our debt collection tools, such
as benefit adjustment, wage garnishment, and credit bureau reporting to collect the
misused amount from you.
If You Disagree With The Decision
Please tell us within 10 days of the date of this letter if you disagree with the
determination that you did not use the money as you agreed. You will also need to
give us any proof showing that the benefits were used properly. We will review the
evidence to see if you are right. We will notify you of our decision.
If we do not hear from you within 10 days and have not received the refund, we will
contact you about our plans to recover the funds.
See Next Page
If You Have Any Questions
If you have any questions, you may call us toll-free at 1-800-772-1213 or call your
local Social Security Office at (5). We can answer most questions over the phone. You can also write or visit any Social
Security office. The office that serves your area is located at:
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
List of Beneficiary(s)