TN 30 (03-96)

NL 00703.413 Notice of Overpayment Due to Posted Earnings — Beneficiary Did Not File Work Report Or Filed Work Report Showing No Earnings -Beneficiary In Suspense Or Terminated Status

Document Identifier for Word Processor: E3413

A. EXHIBIT LETTER

Our records show that you earned (1) .

If you disagree with (2) and can show (3) wrong, please get in touch with any Social Security office and we will correct our records.

(Optional)  
A50.We have changed the month in which you are first entitled to benefits to (1) . This is the month which is most favorable to you.
(Optional)  
A52.When you applied for benefits, you asked that they start in the month which would be most favorable to you. We have reviewed your record, and found that (1) is still the month in which you should first be entitled to benefits.

Based on the earnings on our records, $(4) should have been withheld from our benefits for (5) .

Based on this, you received $(6) more in Social Security benefits than you were due.

 

How To Pay Us Back

3106E
3106A (Optional)

 

If You Think You Should Not Have To Pay Us Back

3106B

 

If You Disagree With the Decision

3106C

If You Want Help With Your Appeal1

3100E

 

Your Responsibilities

3413DIf you earn more than $ (1) this year, please let us know right away, because it can affect the amount of benefits you are due. You will also have to report how much you earned at the end of the year.

 

If Your Have Any Questions

3901C

 

Enclosures:

SSA-3105

Refund Envelope

 

1 If the person has an attorney, omit this paragraph.

B. REQUESTING INSTRUCTIONS

The person who determines the overpayment (generally the benefit authorizer) is responsible for requesting this notice and providing appropriate fill-ins. Listed below are the fill-ins which are generally required:

 

Fill-ins:

(1)A=$ (1) in (2)
   (1) amount of posted earnings
   (2) year of earnings
 B=$ (1) in (2) and $ (3) in (4)
   (1) amount of posted earnings
   (2) year of earnings
   (3) amount of posted earnings
   (4) year of earnings.
 C=$ (1) in (2) ,
   $ (3) in (4) , and
   $ (5) in (6)
   (1) amount of posted earnings
   (2) year of earnings
   (3) amount of posted earnings
   (4) year of earnings
   (5) amount of posted earnings
   (6) year of earnings
 D=$ (1) in (2) ,
    (3) in (4) ,
   $ (5) in (6) , and
   $ (7) in (8) ,
   (1) amount of posted earnings
   (2) year of earnings
   (3) amount of posted earnings
   (4) year of earnings
   (5) amount of posted earnings
   (6) year of earnings
   (7) amount of posted earnings
   (8) year of earnings
(2)A=this amount
 B=any of these amounts
(3)A=it is
 B=they are
  1. amount of deductions (based on earnings in (1) A above)

(5)A=year (Same as in 1A above)
 B=year, and $ (1) for (2)
   (1) amount of deductions
   (2) year
 C=year
   $ (1) for (2) ,
   $ (3) for (4)
   (1) amount of deductions
   (2) year
   (3) amount of deductions
   (4) year
 D=year
   $ (1) for (2) ,
   $ (3) for (4) ,
   $ (5) for (6)
   (1) amount of deductions
   (2) year
   (3) amount of deductions
   (4) year
   (5) amount of deductions
   (6) year
  1. total amount of overpayment

3106E(1) amount of overpayment
A50(1) Month/year
A52(1) month/year
3413D(1) annual earnings limitation

 

NOTE: Insert any applicable ARF or DRC paragraphs after fill-in (6). If necessary, include a paragraph to give the new overpayment balance as a resut of the ARF or DRC.

  • Use 3106A if the liable individual is receiving other program payments (e.g., a person liabl