TN 30 (03-96)

NL 00703.415 Notice of Overpayment Due to Posted Earnings — Beneficiary Filed Work Report But Posted Earnings Exceed Amount Reported — Beneficiary In Suspense or Terminated Status

Document Identifier for Word Processor: E3415

A. EXHIBIT LETTER

You told us you earned (1) . Our records show you earned (2) .

If you disagree with (3) and can show (4) wrong, please get in touch with any Social Security office and we will correct our records.

(Optional)

A50

 

(Optional)

A52

 

Based on the earnings on our records, $ (5) should have been withheld from your benefits for (6) .

Since $ (7) was withheld for (8) , you received $ (9) 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

3413D

 

If You Have Any Questions

3901C

 

Enclosures 2:

Form 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 filll-ins. Listed below are the fill-ins which are generally required:

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

(6)A=year (Same as in (2)A above)
 B=year and $ (1) should have been withheld for (2)
   (1) amount
   (2) year
 C=year,
   $ (1) should have been withheld for (2) , and $ (3) should have been withheld for (4)
   (1) amount
   (2) year
   (3) amount
   (4) year
 D=year,
   $ (1) should have been withheld for (2) , and
   $ (3) should have been withheld for (4) , and
   $ (5) should have been withheld for (6)
   (1) amount
   (2) year
   (3) amount
   (4) year
   (5) amount
   (6) year
  1. amount of benefits actually withheld (base on reported earnings in (1) A above)

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

     

NOTE: Insert any applicable ARF or DRC paragraphs after fill-in (9). If necessary, include a paragraph to give the new overpayment balance as a result of the ARF or DRC.

  • Use 3106A if the liable individual is receiving other program payments (e.g., a person liable for payment of title II overpayment receives Black Lung or title XVI payments).

  • Use A50 if there is a month of entitlement change and the election was before age 65. Use A52 if the month of entitlement is being confirmed.

  • Use 3106E, 3106B, 3106C, 3413D and 3901C in all cases.

  • Refer to NL 00703.106 for 3106B and 3106C text.

  • Refer to NL 00703.100 for 3100E text.

  • Refer to NL 00703.413 for 3413D text and fill-in.

  • Refer to NL 00703.005E. for 3901C text.

C. TYPING INSTRUCTIONS

The individual's name and address, if not show, can be taken from the latest Form
SSA-3926-EP.

Because the fill-ins may vary according to the different situations, follow the requester's typing instructions carefully.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900703415
NL 00703.415 - Notice of Overpayment Due to Posted Earnings -- Beneficiary Filed Work Report But Posted Earnings Exceed Amount Reported -- Beneficiary In Suspense or Terminated Status - 03/04/1996
Batch run: 01/27/2009
Rev:03/04/1996