TN 55 (05-10)
NL 00703.963 Notification of Withholding to Collect a Civil Monetary Penalty (and Assessment)
Document Identifier for Word Processor: E3963
A. Exhibit Letter
(PEN017) We are writing to let you know that we have received a copy of the correspondence sent to (1) dated (2) from the Office of the Chief Counsel to the Inspector General. In that correspondence, you were notified that the Office of the Inspector General has imposed a Civil Monetary Penalty of $ (3) (4) (5) against (6). As of today's date, (7) still owe(s) (8). We plan to withhold from $ (9) (10) until we collect the total amount due.
(PAYC35) What You Will Receive and When
(PEN018) Because (1) entered into a settlement agreement with the office of the Inspector General, we will withhold (2) from (3) Supplemental Security Income payments. (4) will receive (5) for (6). (7) will receive this amount on or about the first of (8).
(PEN019) Because (1) entered into a settlement agreement with the Office of the Inspector General, we will withhold (2) from (3) Social Security benefits. (4) will receive (5) for (6). (7) will receive this amount on or about the (8) of (9).
If (10) pay(s) Medicare premiums, we will deduct them from the benefits before withholding any amount to collect the debt. Medicare coverage will not be affected.
(11) will resume receiving the full regular monthly payment after this debt has been paid in full.
(PEN020) We will withhold (1) Supplemental Security Income payments to collect this debt.
(2) may resume receiving the regular monthly payment after this debt has been paid in full.
(PEN021) We will withhold all of (1) Social Security benefits to collect this debt.
If (2) pay(s) Medicare premiums, we will exclude that amount from what we withhold to collect this debt. Medicare coverage will not be affected.
(3) will resume receiving the full regular monthly payment after this debt has been paid in full.
(MESC01) What You Can Do
(PEN022) We will withhold (1) unless, within 30 days of the date you receive this letter, you:
Pay us the full amount you owe, or
Ask us to review our finding that you still owe us the amount stated above.
(PAYC36) How To Pay Us
(PEN023) You can pay the civil monetary penalty (1) in full with a money order, certified check or bank draft. Payment should include your full name, social security number, and the letters "CMP," placed prominently on the face of the payment and should be mailed to:
Social Security Administration
Mid-Atlantic Program Service Center
P.O. Box 3430
Philadelphia, PA 19122
(RCYC02) Do You Think That You Do Not Owe This Money?
(ALS169) You may ask us to review our finding that you still owe the money. You may have evidence showing that the information about the civil monetary penalty (1) stated at the beginning of this letter is not correct or you have paid some or all of the debt. If so, give us this evidence when you ask for review. We will review the evidence you give us and the information we have. We will send you a letter with our decision. If we find that you do not owe us this amount, then we will correct our records. We will not review the Office of the Inspector Generals decision to impose the civil monetary penalty (2).
If you want a review, you must tell us within 60 days. The 60 days start the day after you get this letter. We assume you got this letter 5 days after the date on it unless you show us that you did not get it within the 5-day period. You must have a good reason for waiting more than 60 days to ask for the review. If you ask for review within 30 days, we will not begin to withhold money until we examine the case and send you a letter with our decision.
You have to ask for a review in writing. Contact one of our offices if you want help. We will ask you to sign a form SSA-561-U2, called "Request for Reconsideration."
(REFC01) If You Have Any Questions
(REF032) (Referral paragraph)
(REF038) (Referral paragraph)
(REF061) (Referral paragraph)
(CTDO) (Aurora – Referral paragraph. Contains caption)
(PEN017) (1) you/recipient’s name
(2) Date of letter
(3) Amount of CMP
(4) and an assessment of/NULL
(5) Amount of assessment/NULL
(6) you/name (same as #1)
(7) you/name (same as #1)
(8) Amount still owed
(10) Social Security benefits or Supplemental Security Income payments
(PEN018) (1) you/he/she
(2) Amount to be withheld
(5) Amount to be paid each month
(6) MM/YYYY partial payment to begin
(8) Month payment will be received
(PEN019) (1) you/he/she
(2) Amount to be withheld
(5) Amount to be paid
(6) MM/YYYY payment to be received
(8) third/second Wed./third Wed./fourth Wed.
(9) Month payment will be received
(PEN020) (1) your/his/her
(PEN021) (1) your/his/her
(PEN022) (1) Social Security benefits or Supplemental Security Income payments
(PEN023) (1) and assessment/NULL
(ALS169) (1) and assessment/NULL
(2) and assessment/NULL
B. Requesting Instructions
This notice was developed specifically for CMP debts. Do not use any other UTIs other than those listed in this exhibit. Waiver does not apply. This exhibit should be used for notifying a debtor whenever SSA will be withholding their benefits/payments to collect a CMP debt. This exhibit contains paragraph choices for Title II full and partial withholding and Title XVI full and partial withholding. Please choose the paragraphs under the particular caption that are appropriate to that Title. These paragraphs are available in AURORA and DPS (under the overpayment umbrella). The UTI numbers are listed next to the paragraphs.
Use PEN018 if recovering by partial withholding from Title XVI benefits.
Use PEN019 if recovering by partial withholding from Title II benefits.
Use PEN020 if recovering by full withholding from Title XVI benefits.
Use PEN021 if recovering by full withholding from Title II benefits.