TN 2 (09-11)

NL 00720.295 RFU Refund

RFU001 REQUEST FOR REFUND - OVERPAID PERSON IN NONPAY STATUS NO CROSS PROGRAM ADJUSTMENT POSSIBLE (A19) (G13)

(Requested/Generated)

Caption: How To Pay Us Back

You should refund this overpayment within 30 days. Please make your check or money order payable to "Social Security Administration," and send it to us in the enclosed envelope. Include  (1)  claim number (as shown above) on your check or money order.

If you cannot refund the full  (2)  now, please send:

  • A partial payment

  • An explanation of why you cannot pay the full amount now, and

  • A plan to replay the money

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (2) - Requested As A Money Amount in Format $$$$$.¢¢

Overpayment Amount

RFU003 REQUEST FOR REFUND AND ADJUSTMENT PROPOSED - OVERPAID PERSON IN NONPAY STATUS AND IS REPRESENTATIVE PAYEE FOR OTHER - OVERPAYMENT EXCEEDS MONTHLY PAYMENT (A26)

(Requested)

Caption: How To Pay Us Back

You should refund this overpayment within 30 days. Please make your check or money order payable to "Social Security Administration," and send it to us in the enclosed envelope. Always include your claim number (as indicated above) on the check or money order. If you cannot refund the full  (1)  now, you should submit: (a) a partial payment; (b) an explanation of your financial circumstances; and (c) a definite plan for repaying the balance.

If we do not receive your refund within 30 days, we plan to recover the overpayment by withholding  (2)  full benefit beginning with the payment you would normally receive for  (3)  about  (4)  . We will continue withholding the benefit you receive for  (5)  until the overpayment has been fully recovered.

Fill-in values:

Fill-in (1) Requested As A Money Amount in Format $$$$$.¢¢

Amount

Fill-in (2) Requested As a Language

First Name(s) of the BIC(s)

Fill-in (3) Requested As A One Position Alpha Character

Choice 1: (A) him

Choice 2: (B) her

Choice 3: (C) them

Fill-in (4) Requested As A Date In Format Shown Below

MM/DD/CCYY

Fill-in (5) Requested As A One Position Alpha Character

Choice 1: (A) him

Choice 2: (B) her

Choice 3: (C) them

RFU007 SSI OFFSET NOT APPLICABLE (A59)

(Requested)

Caption: Your Benefits

Our records show that  (1)  did not get SSI money for  (2)  . So we can refund all of the Social Security money we held.

Fill-in values:

Fill-in (1) Systems Generated

Choice 1: you

Choice 2: Beneficiary's Name

Fill-in (2) Requested As A Date In Format Shown Below

Choice 1: MM/CCYY

Choice 2: MM/CCYY through MM/CCYY

RFU008 REFUND/RETURNED CHECK(S) USED TO REDUCE OVERPAYMENT (A34)

(Requested)

Caption: Your Benefits

We used the amount refunded to replace  (1)  the money we  (2)   (3)  .

Fill-in values:

Fill-in (1) Requested As A One Position Alpha Character

Choice 1: (A) some of

Choice 2: (B) null

Fill-in (2) Requested As A One Position Alpha Character

Choice 1: (A) incorrectly paid

Choice 2: (B) overpaid

Fill-in (3) Systems Generated

Choice 1: you

Choice 2: him

Choice 3: her

Choice 4: Beneficiary's Name

RFU012 REQUEST FOR REFUND AND ADJUSTMENT PROPOSED — OVERPAID PERSON IN CURRENT PAY — OVERPAYMENT EXCEEDS MONTHLY PAYMENT (A24)

(Requested/Generated)

Caption: How To Pay Us Back

You should refund this overpayment of  (1)  within 30 days. Please make your check or money order payable to "Social Security Administration," and send it to us in the enclosed envelope. Include  (2)  claim number (as shown above) on your check or money order.

If we do not receive your refund within 30 days, we will hold back  (3)  full benefit starting with the payment you would normally receive  (4)  about  (5)  . We will continue holding back  (6)  benefits until we recover the overpayment.

If you cannot refund the full overpayment now or cannot afford to have us hold back  (7)  , full benefit, you may ask us to hold back a smaller amount each month. Contact us to discuss your plan for repaying the balance. You may need to show us proof of  (8)  assets, monthly income, and expenses.

Fill-in values:

Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢

Overpayment Amount

Fill-in (2) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (3) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (4) - Systems Generated

Choice 1: null

Choice 2: for him

Choice 3: for her

Fill-in (5) - Requested As A Date In Format Shown Below

MM/DD/YYYY

Fill-in (6) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (7) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

Fill-in (8) - Systems Generated

Choice 1: your

Choice 2: his

Choice 3: her

RFU020 FOREIGN REFUND REQUEST NONPAY STATUS (F19)

Caption: How To Pay Us Back

(System Generated)

You should refund this overpayment within 30 days. Please make your check or money order payable to "Social Security Administration," and send it to us in the enclosed envelope. Always include  (1)  claim number (as indicated above) on the check or money order. If you cannot refund the full  (2)  now, you should submit:

a. partial payment,

b. an explanation of your financial circumstances, and

c. a definite plan for repaying the balance.

 If you pay us by check or money order, make sure that the check or money order is in United States (U.S.) dollars or in local currency equal to U.S. dollars. When you pay us in local currency, we use the exchange rates in effect at the time we get your payment. If this causes a difference between the amount you pay us and the amount you owe us, we will let you know. If you cannot mail your payment to us, please go to the nearest U.S. Embassy or consulate. They will help you make the refund.

Fill-in values:

Fill-in (1)

Choice 1: Beneficiary's name possessive

Choice 2: your

Fill-in (2)

Overpayment amount in $$$$$¢¢


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900720295
NL 00720.295 - RFU Refund - 09/17/2013
Batch run: 09/17/2013
Rev:09/17/2013