TN 30 (03-96)

NL 00703.419 Notice of Overpayment Due To Posted Earnings — Beneficiary Filed Work Report But Posted Earnings Exceed Amount Reported — Monthly Earnings Test Applies — Beneficiary In Suspense Or Terminated Status

Document Identifier for Word Processor: E3419

A. EXHIBIT LETTER

You told us you earned $ (1) in (2) . Our records show that you earned $ (3) in (4) . We assume that you worked in all months of (5) after you became entitled to Social Security benefits.

(Optional)

3419B

Also, you told us you earned $ (1) . Our records show you earned (2) .

If you disagree with (6) and can show (7) wrong, or if you did little or no work in (8) after you became entitled to Social Security benefits, please get in touch with any Social Security office and we will correct our records.

(Optional)

A50

 

(Optional)

A52

 

Based on the information we have now, $ (9) should have been withheld from your benefits for (10) . Since $ (11) was withheld for (12) , you received $ (13) more in Social Security benefits than you were due.

 

How To Pay Us Back

3106E

(Optional)

3106A

 

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

 

Information About Work and Earnings
3417B

 

You Responsibilities

3413D

 

If You 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.

 

Fill-ins:

  1. amount of reported earnings

  2. monthly test year

  3. amount of posted earnings

  4. monthly test year

  5. monthly test year

3419B (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
(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) and
   $ (5) in (6)
   (1) amount of posted earnings
   (2) year
   (3) amount of posted earnings
   (4) year
   (5) amount of posted earnings
   (6) year
(6)A=this amount
 B=any of these amounts
(7)A=it is
 B=they are
  1. monthly test year

  2. amount that should have been withheld for monthly test year

(10)A=monthly test year
 B=monthly test year and $ (1) should have been withheld for (2)
   (1) amount
   (2) year
 C=monthly test 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=monthly test year
$ (1) should have been withheld for (2) ,
   $ (3) should have been withheld for (4) ,
   $ (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 for monthly test year

(12)A=monthly test year
 B=monthly test year and $ (1) was withheld for (2)
   (1) amount
   (2) year
 C=monthly test year
   $ (1) was withheld for (2) , and
   $ (3) was withheld for (4)
   (1) amount
   (2) year
   (3) amount
   (4) year
 D=monthly test 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 (13). If necessary, include a paragraph to give the new overpayment balance as a result of the ARF or DRC.

  • Use 3419B if more than one year is enforced.

  • Use 3106A if the liable individual is receiving other program payments (e.g., a person liable for repayment 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, 3417B, 3413D and 3901C in all cases.

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

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

  • Refer to NL 00703.417 for 3417B and 3417C text and fill-ins.

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

C. TYPING INSTRUCTIONS

The individual's name and address, if not shown, 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/0900703419
NL 00703.419 - Notice of Overpayment Due To Posted Earnings -- Beneficiary Filed Work Report But Posted Earnings Exceed Amount Reported -- Monthly Earnings Test Applies -- Beneficiary In Suspense Or Terminated Status - 03/04/1996
Batch run: 01/27/2009
Rev:03/04/1996