OPTC01 – CAPTION
         Overpayment Information
         OPT029 – NEW OVERPAYMENT – OVERPAYMENT NOT DUE TO TERMINATION
         We paid (1) (2) for (3). Since we should have paid (4) (5) for (6), we paid (7) (8)
            more than (9) (10) due.
         
         
            
               
                  
                  
               
               
                  
                  
                     
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                         Fill-in values: 
                        
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                     | Fill-in (1) | 
                     
                     
                           
                        
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                         Choice 1 
                        
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                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) 
                        
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                         Choice 2 
                        
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                         you 
                        
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                         Fill-in (2) 
                        
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                         Sum of the Monthly Benefit Credited (MBCs) on the Pre-MBR starting with the internal
                           Business Start Date and ending with Current Operating Month (COM) minus 1 month in
                           the format $$$$$.¢¢
                         
                        
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                         Fill-in (3) 
                        
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                         Choice 1 
                        
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                         Internal Business Start Date in format Month CCYY 
                        
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                         Choice 2 
                        
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                         Internal Business Start Date plus “and” plus Current Operating Month (COM) minus 1
                           month in the format Month CCYY
                         
                        
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                         Choice 3 
                        
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                         Internal Business Start Date plus “through” plus Current Operating Month (COM) minus
                           1 month in the format Month CCYY
                         
                        
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                         Fill-in (4) 
                        
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                         Choice 1 
                        
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                         him 
                        
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                         Choice 2 
                        
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                         her 
                        
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                         Choice 3 
                        
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                         you 
                        
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                         Fill-in (5) 
                        
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                         Sum of the Monthly Benefit Credited (MBCs) on the Pre-MBR starting with the internal
                           Business Start Date and ending with Current Operating Month (COM) minus 1 month in
                           the format $$$$$.¢¢
                         
                        
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                     | Fill-in (6) | 
                     
                     
                           
                        
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                         Choice 1 
                        
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                         Internal Business Start Date in format Month CCYY 
                        
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                         Choice 2 
                        
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                         Internal Business Start Date plus “and” plus Current Operating Month (COM) minus 1
                           month in the format Month CCYY
                         
                        
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                         Choice 3 
                        
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                         Internal Business Start Date plus “through” plus Current Operating Month (COM) minus
                           1 month in the format Month CCYY
                         
                        
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                         Fill-in (7) 
                        
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                         Choice 1 
                        
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                         him 
                        
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                         Choice 2 
                        
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                         her 
                        
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                         Choice 3 
                        
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                         you 
                        
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                         Fill-in (8) 
                        
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                         Difference between Trigger Record New Overpayment Amount (TR-NEW-OPA-AMOUNT) and total
                           Trigger Record Other Beneficiary Overpayment Amount (TR-OTH-BENE-OPA) in the format
                           $$$$$.¢¢
                         
                        
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                         Fill-in (9) 
                        
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                         Choice 1 
                        
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                         he 
                        
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                         Choice 2 
                        
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                         she 
                        
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                         Choice 3 
                        
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                         you 
                        
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                         Fill-in (10) 
                        
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                         Choice 1 
                        
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                         was 
                        
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                         Choice 2 
                        
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                         were 
                        
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         OPT064 – EXPLAINS TO A WORKING BENEFICIARY THERE IS AN OVERPAYMENT ON HIS OR HER
               RECORD FOR ONE YEAR BECAUSE THE EARNINGS THEY REPORTED IS DIFFERENT FROM WHAT SSA
               RECORDS SHOW
         We recently found that the earnings (1) for (2) and the earnings information we have
            do not match. (3) told us (4) earned (5) in (6) but our records show that (7) earned
            (8). If our records are correct, we paid (9) (10) too much.
         
         
            
               
                  
                  
               
               
                  
                  
                     
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                         Fill-in values 
                        
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                         Fill-in (1) 
                        
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                         Choice 1 
                        
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                         "reported for” plus Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) 
                        
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                         Choice 2 
                        
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                         “reported for you” 
                        
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                         Fill-in (2) 
                        
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                         Year in the format CCYY 
                        
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                         Fill-in (3) 
                        
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                         Choice 1 
                        
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                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) 
                        
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                         Choice 2 
                        
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                         You 
                        
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                         Fill-in (4) 
                        
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                         Choice 1 
                        
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                         he 
                        
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                         Choice 2 
                        
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                         she 
                        
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                         Choice 3 
                        
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                         you 
                        
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                         Fill-in (5) 
                        
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                         Amount of reported earnings (AORE) 
                        
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                         Fill-in (6) 
                        
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                         Year of Earnings Report (YOER) in the format CCYY 
                        
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                         Fill-in (7) 
                        
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                         Choice 1 
                        
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                         he 
                        
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                         Choice 2 
                        
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                         she 
                        
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                         Choice 3 
                        
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                         you 
                        
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                         Fill-in (8) 
                        
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                         Amount of reported earnings (AORE) 
                        
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                         Fill-in (9) 
                        
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                         Choice 1 
                        
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                         him 
                        
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                         Choice 2 
                        
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                         her 
                        
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                         Choice 3 
                        
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                         you 
                        
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                         Fill-in (10) 
                        
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                         Overpayment amount 
                        
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         OPT065 – EXPLAINS TO A WORKING BENEFICIARY THAT BECAUSE THE EARNINGS PREVIOUSLY
               POSTED FOR MULTIPLE YEARS ARE LESS THAN THE EARNINGS ON THE MASTER EARNINGS RECORD,
               THERE ARE OVERPAYMENTS FOR MULTIPLE YEARS
         We recently found that the earnings reported for (1) for the years shown below and
            the earnings on our records do not match. If our records are correct, we paid (2)
            (3) too much.
         
         
            
               
                  
                  
               
               
                  
                  
                     
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                         Fill-in values: 
                        
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                         Fill-in (1) 
                        
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                         Choice 1 
                        
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                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) 
                        
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                         Choice 2 
                        
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                         you 
                        
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                         Fill-in (2) 
                        
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                         Choice 1 
                        
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                         you 
                        
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                         Choice 2 
                        
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                         him 
                        
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                         Choice 3 
                        
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                         her 
                        
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                         Fill-in (3) 
                        
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                         Overpayment amount in the format $$$$$.¢¢ 
                        
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         OPT084 – EXPLAINS TO A WORKING BENEFICIARY THAT BECAUSE THE EARNINGS PREVIOUSLY
               POSTED FOR A SINGLE YEAR ARE LESS THAN THE EARNINGS ON THE MASTER EARNINGS RECORD
               AND NO BENEFITS WERE WITHHELD FOR THIS YEAR, THERE IS AN OVERPAYMENT FOR JUST ONE
               YEAR
         Our records show that (1) had earnings in (2) of (3) that we did not consider when
            we paid (4). If our records are correct, we paid (5) (6) too much.
         
         
            
               
                  
                  
               
               
                  
                  
                     
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                         Fill-in values: 
                        
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                         Fill-in (1) 
                        
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                         Choice 1 
                        
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                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) 
                        
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                         Choice 2 
                        
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                         you 
                        
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                         Fill-in (2) 
                        
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                         Year of Earnings Report (YOER) in the format CCYY 
                        
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                         Fill-in (3) 
                        
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                         Amount of reported earnings (AORE) 
                        
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                         Fill-in (4) 
                        
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                         Choice 1 
                        
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                         him 
                        
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                         Choice 2 
                        
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                         her 
                        
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                         Choice 3 
                        
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                         you 
                        
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                         Fill-in (5) 
                        
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                         Choice 1 
                        
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                         him 
                        
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                         Choice 2 
                        
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                         her 
                        
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                         Choice 3 
                        
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                         you 
                        
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                         Fill-in (6) 
                        
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                         Overpayment amount 
                        
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         OPT085 – TELLS THE BENEFICIARY THE OVERPAYMENT AMOUNT
         (1), (2) us (3).
         
            
               
                  
                  
               
               
                  
                  
                     
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                         Fill-in values: 
                        
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                         Fill-in (1) 
                        
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                         Choice 1 
                        
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                         After all the changes (use when earnings caused more than 1 adjustment) 
                        
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                         Choice 2 
                        
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                         As a result (use when earnings caused a single adjustment) 
                        
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                         Fill-in (2) 
                        
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                         Choice 1 
                        
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                         you owe 
                        
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                         Choice 2 
                        
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                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “owes” 
                        
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                         Fill-in (3) 
                        
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                         Total overpayment amount due in $$$$$.¢¢ format 
                        
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         OPT086 – EARNINGS PREVIOUSLY POSTED FOR MULTIPLE YEARS ARE LESS THAN THE
               EARNINGS ON THE MASTER RECORD AND NO BENEFITS WERE WITHHELD, THEREFORE, THERE ARE
               OVERPAYMENTS FOR EACH YEAR
         Our records show that (1) had earnings for the years shown below that we did not consider
            when we paid (2). If our records are correct, we paid (3) (4) too much.
         
         
            
               
                  
                  
               
               
                  
                  
                     
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                         Fill-in values: 
                        
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                         Fill-in (1) 
                        
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                         Choice 1 
                        
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                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) 
                        
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                         Choice 2 
                        
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                         you 
                        
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                         Fill-in (2) 
                        
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                         Choice 1 
                        
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                         him 
                        
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                         Choice 2 
                        
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                         her 
                        
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                         Choice 3 
                        
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                         you 
                        
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                         Fill-in (3) 
                        
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                         Choice 1 
                        
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                         him 
                        
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                         Choice 2 
                        
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                         her 
                        
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                         Choice 3 
                        
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                         you 
                        
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                         Fill-in (4) 
                        
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                         Total overpayment amount 
                        
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         OPT087 – CHART HEADING UTI THAT PROVIDES THE WORKING BENEFICIARY THE EARNINGS
               POSTED WITH NO BENEFITS PREVIOUSLY WITHHELD FOR THAT YEAR EARNINGS
         Earnings On
         Year Our Records
         OPT088 – EXPLAINS TO A WORKING BENEFICIARY IN A CHART THE EARNINGS POSTED WHEN
               NO BENEFITS WERE PREVIOUSLY WITHHELD FOR THESE EARNINGS
         (1) (2)
         
            
               
                  
                  
               
               
                  
                  
                     
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                         Fill-in values: 
                        
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                         Fill-in (1) 
                        
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                         Year of Earnings Report (YOER) in format CCYY 
                        
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                         Fill-in (2) 
                        
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                         Amount of reported earnings (AORE) 
                        
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         OPT096 – PRIOR OVERPAYMENT WITH A PROTEST AND PROTEST DECISION STILL
               PENDING
         We already told you that we paid (1) (2) too much for a past period. We will send
            you another letter to let you know what we will do about the recovery of that money.
         
         
            
               
                  
                  
               
               
                  
                  
                     
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                         Fill-in values 
                        
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                         Fill-in (1) 
                        
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                         Choice 1 
                        
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                         you 
                        
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                         Choice 2 
                        
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                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) 
                        
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                         Fill-in (2) 
                        
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                         Choice 1 
                        
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                         Due process overpayment amount in the format $$$$$.¢¢ 
                        
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                         Choice 2 
                        
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                         Null 
                        
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         OPT097 – RECOVERY OF AN INCORRECT PAYMENT
         Once we get back the money (1) not due for this year, we will start to withhold (2)
            benefits to get back the other money (3).
         
         
            
               
                  
                  
               
               
                  
                  
                     
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                         Fill-in values 
                        
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                         Fill-in (1) 
                        
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                         Choice 1 
                        
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                         you were 
                        
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                         Choice 2 
                        
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                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “was” 
                        
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                         Fill-in (2) 
                        
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                         Choice 1 
                        
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                         your 
                        
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                         Choice 2 
                        
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                         his 
                        
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                         Choice 3 
                        
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                         her 
                        
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                         Fill-in (3) 
                        
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                         Choice 1 
                        
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                         you owe 
                        
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                         Choice 2 
                        
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                         he owes 
                        
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                         Choice 3 
                        
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                         she owes 
                        
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         OPT107 – FULL OR PARTIAL WITHHOLDING FOR ONE MONTH
         We will withhold up to 50 percent from (1) (2) payment to recover the money we (3)
            (4). This is the payment you will receive on or about (5).
         
         
            
               
                  
                  
               
               
                  
                  
                     
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                         Fill-in values: 
                        
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                         Fill-in (1) 
                        
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                         Choice 1 
                        
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                         your 
                        
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                         Choice 4 
                        
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                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) 
                        
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                         Fill-in (2) 
                        
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                         Date of overpayment recovery in the format Month CCYY 
                        
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                         Fill-in (3) 
                        
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                         Choice 1 
                        
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                         overpaid 
                        
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                         Choice 2 
                        
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                         incorrectly paid 
                        
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                         Fill-in (4) 
                        
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                         Choice 1 
                        
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                         you 
                        
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                         Choice 2 
                        
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                         him 
                        
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                         Choice 3 
                        
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                         her 
                        
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                         Fill-in (5) 
                        
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                         Date the overpayment will be deducted in the format Month DD, CCYY 
                        
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         OPT122 – NEW OVERPAYMENT DUE TO RETROACTIVE TERMINATION
         Since we did not stop (1) payments until (2), (3) paid (4) too much in benefits.
         
            
               
                  
                  
               
               
                  
                  
                     
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                         Fill-in values: 
                        
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                         Fill-in (1) 
                        
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                         Choice 1 
                        
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                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) 
                        
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                         Choice 2 
                        
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                         your 
                        
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                         Fill-in (2) 
                        
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                         Current Operating Month (COM) in format Month CCYY 
                        
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                         Fill-in (3) 
                        
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                         Choice 1 
                        
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                         he was 
                        
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                         Choice 2 
                        
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                         she was 
                        
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                         Choice 3 
                        
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                         you were 
                        
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                         Fill-in (4) 
                        
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                         New overpayment amount in $$$$$.¢¢ 
                        
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         OPT123 – TOTAL OVERPAYMENT INCLUDES PRIOR OVERPAYMENT
         (1) total overpayment of (2) includes (3) prior overpayment.
         
            
               
                  
                  
               
               
                  
                  
                     
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                         Fill-in values: 
                        
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                         Fill-in (1) 
                        
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                         Choice 1 
                        
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                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) 
                        
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                         Choice 2 
                        
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                         Your 
                        
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                         Fill-in (2) 
                        
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                         Due Process Overpayment (DPO) on the Post-MBR in format $$$$$.¢¢ 
                        
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                         Fill-in (3) 
                        
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                         Choice 1 
                        
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                         his 
                        
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                         Choice 2 
                        
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                         her 
                        
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                         Choice 3 
                        
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                         your 
                        
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         OPT125 – BENEFICIARY'S OVERPAYMENT BEING RECOVERED FROM ANOTHER
               AUXILIARY
         We paid other person(s) on this record (1) more in benefits than we should have. Under
            Social Security law, you are responsible for this overpayment.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                         Other beneficiary's overpayment amount in format $$$$$.¢¢ 
                        
                      | 
                     
                  
               
            
          
         OPT127 – ADVISES OF OVERPAYMENT RECOVERY AMOUNT (OPRA) ON POST-MBR
         We used (1) of (2) benefits to recover (3) of an overpayment on this record.
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                         Overpayment Recovery Amount (OPRA) on Post-MBR in format $$$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         all 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         part 
                        
                      | 
                     
                  
               
            
          
         OPT128 – BENEFICIARY’S NEW OVERPAYMENT, BENEFICIARY’S PRIOR OVERPAYMENT AND
               ANOTHER BENEFICIARY’S OVERPAYMENT
         (1) total overpayment of (2) includes (3) prior overpayment and another beneficiary's
            overpayment that (4) (5) liable for under Social Security law.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Due Process Overpayment (DPO) amount on the Post-MBR in format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (5) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         is 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         are 
                        
                      | 
                     
                  
               
            
          
         OPT131 – REMAINING BALANCE ON PRIOR OVERPAYMENT
         (1) (2) an outstanding balance remaining on a prior overpayment. That remaining balance
            is (3).
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | Fill-in (1) | 
                     
                      | 
                     
                  
                  
                     
                     | Choice 1 | 
                     
                     Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) | 
                     
                  
                  
                     
                     | Choice 2 | 
                     
                     You | 
                     
                  
                  
                     
                     | Fill-in (2) | 
                     
                      | 
                     
                  
                  
                     
                     | Choice 1 | 
                     
                     has | 
                     
                  
                  
                     
                     | Choice 2 | 
                     
                     have | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                         Show the remaining overpayment amount or the old overpayment amount in format $$$$$$.¢¢ 
                        
                      | 
                     
                  
               
            
          
         OPT132 – PIC A (H) DIES OR PIC B DIES AND HAVE JOINT BANK DATA ON MBR AND THERE
               IS AN OVERPAYMENT
         We paid (1) more in benefits than we should have. We deposited (2) benefits for (3)
            into a bank account which (4) also owned. We can't pay benefits for the month of death,
            (5), or later. Because (6) a joint owner of the bank account, (7) overpaid (8).
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         New overpayment amount 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         NH-FULL name (possessive) when PIC A died and PIC B is responsible for the overpayment 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) when
                           PIC B died and PIC A is responsible for the overpayment
                         
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Beneficiary's date of death when Beneficiary Date of Death (BDOD) = Current Operating
                           Month (COM) minus 1 month
                         
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary's date of death plus “and” plus the Current Operating Month (COM) minus
                           1 month when the Beneficiary Date of Death (BDOD) = Current Operating Month (COM)
                           minus 2 months
                         
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         Beneficiary's date of death plus “through” plus Current Operating Month (COM) minus
                           1 month when the Beneficiary Date of Death (BDOD) > Current Operating Month (COM)
                           minus 2 months
                         
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (5) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Beneficiary Date of Death (BDOD) for PIC A in the format Month CCYY 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary Date of Death (BDOD) for PIC B in the format Month CCYY 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (6) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “is” 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         you are 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (7) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “is” 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         you are 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (8) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Trigger Record New Overpayment Amount (WS-TR-NEW-OPA) in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Trigger Record Other Beneficiary Overpayment Amount (WS-TR-OTH-BENE-OPA) for WS-TR-OTH-OPA-BIC
                           = A or WS-TR-OTH-BENE-OPA-BIC = B in the format $$$$$.¢¢
                         
                        
                      | 
                     
                  
               
            
          
         OPT133 – BENEFICIARY(S) DIE AND OVERPAYMENT RECOVERED FROM ANOTHER ENTITLED
               BENEFICIARY
         We paid you (1) more in benefits than we should have. The overpayment occurred because
            we did not stop (2) benefits for (3). We can't pay benefits for the month of death,
            (4), or later.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         New overpayment amount 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         If more than one dead beneficiary is overpaid and overpayments are being recovered
                           from another entitled beneficiary, then show the total amount of all overpaid beneficiaries
                         
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) for
                           one overpaid beneficiary
                         
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus
                           “and” for two overpaid beneficiaries followed by the Beneficiary’s Given Name (BGN)
                           plus Beneficiary’s Last Name (BLN) (possessive) for the second overpaid beneficiary
                         
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) followed
                           by a comma followed by Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name
                           (BLN) (possessive) for the second overpaid beneficiary plus “and” followed by Beneficiary’s
                           Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) for the third overpaid
                           beneficiary
                         
                        
                        NOTE:  If more than three dead beneficiaries with the same BDOD and overpaid, then an Incomplete
                           notice will be generate (see Incomplete Notices under the Completion Code section
                           for the CODE and more information)
                         
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Beneficiary's date of death when Beneficiary Date of Death (BDOD) = Current Operating
                           Month (COM) minus 1 month
                         
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary's date of death plus “and” plus the Current Operating Month (COM) minus
                           1 month when the BDOD = COM minus 2 months
                         
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         Beneficiary's date of death plus “through” plus COM minus 1 month when the Beneficiary
                           Date of Death (BDOD) > Current Operating Month (COM) minus 2 months
                         
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                         Beneficiary Date of Death (BDOD) 
                        
                      | 
                     
                  
               
            
          
         OPT147 – DUE PROCESS TITLE II OVERPAYMENT RECOVERY LESS THAN FULL MONTHLY
               BENEFIT AMOUNT
         We will start recovering this overpayment by withholding up to 50 percent of the payment
            (1) will receive on or about (2).
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment recovery date in Month DD, CCYY format 
                        
                      | 
                     
                  
               
            
          
         OPT148 – TITLE XVI (SSI) UNDERPAYMENT USED TO REDUCE OR RECOVERY A TITLE II
               OVERPAYMENT (CROSS PROGRAM RECOVERY PHASE 3)
         We used (1) of (2) SSI benefits to recover some or all of an overpayment on this record.
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                         Deductions Additions History Amount (DAH-AMOUNT) that corresponds to the Deductions
                           Additions History Type of Payment Code (DAH-TOP) = P and Deductions Additions History
                           Item Code (DAH-ITEM) = 382 in the format $$$$$$.¢¢
                         
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
               
            
          
         OPT149 – TITLE XVI (SSI) UNDERPAYMENT NOT USED TO REDUCE OR RECOVERY A TITLE II
               OVERPAYMENT (CROSS PROGRAM RECOVERY PHASE 3)
         We did not use any of (1) SSI benefits to recover an overpayment on this record.
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
               
            
          
         OPT216 – OVERPAYMENT CAUSED BY SUBSTANTIAL GAINFUL WORK ACTIVITY (SGA) DURING
               THE EXTENDED PERIOD OF ELIGIBILITY (EPE) OR DISABILITY CESSATION DUE TO
               SGA
         (1) received (2) too much in benefits because of (3) work activity. Please read the
            rest of this letter carefully. In it, we explain the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 4 
                        
                      | 
                     
                     
                         Number Holder’s Beneficiary Given Name (BGN) plus Beneficiary Last Name (BLN) (possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT217 – OVERPAYMENT ESTABLISHED VIA CROSS PROGRAM RECOVERY (CPR) TO RECOVER A
               TITLE VIII SPECIAL VETERANS BENEFITS (SVB) PAID IN EXCESS 
         (1) received (2) too much in Special Veterans Benefit (SVB) payments. Please read
            the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                      | 
                     
                  
               
               
                  
                  
                     
                     | Fill-in (1) | 
                     
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | Fill-in (2) | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | Fill-in (3) | 
                     
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT218 – OVERPAYMENT CAUSED DUE TO INCORRECT PAYMENTS FOR MEDICARE SERVICES
               
         (1) received (2) too much in benefits because of incorrect payments for Medicare services.
            Please read the rest of this letter carefully. In it, we explain the changes we made
            to (3) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT219 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFCIARY WAS CONVICTED OF A CRIME
               OR IMPRISONED FOR MORE THAN 30 DAYS DUE TO FELONIOUS HOMICIDE
         (1) received (2) too much in benefits because (3) criminal conviction and imprisonment
            for more than 30 days. Please read the rest of this letter carefully. In it, we explain
            the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT220 – OVERPAYMENT CAUSED BY WINDFALL OFFSET 
         (1) received (2) too much in benefits because (3) received Supplemental Security Income
            (SSI) payments (4) (5). Please read the rest of this letter carefully. In it, we explain
            the changes we made to (6) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         from 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         in 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (5) 
                        
                      | 
                     
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Month CCYY through Month CCYY 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Month CCYY 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (5) 
                        
                      | 
                     
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT221 – OVERPAYMENT ESTABLISHED BECAUSE MORE THAN ONE PAYMENT WAS CASHED FOR
               THE SAME MONTH
         (1) received (2) too much in benefits because we should not have paid two payments
            for the same month(s). Please read the rest of this letter carefully. In it, we explain
            the changes we made to (3) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT222 – OVERPAYMENT ESTABLISHED DUE TO INVALID FAMILY RELATIONSHIPS
               
         (1) received (2) too much in benefits because (3) did not meet the relationship requirements
            to receive benefits. Please read the rest of this letter carefully. In it, we explain
            the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT223 – OVERPAYMENT ESTABLISHED BECAUSE OF INVALID ENTITLEMENT
         (1) received (2) too much in benefits because (3) did not qualify for benefits. Please
            read the rest of this letter carefully. In it, we explain the changes we made to (4)
            benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT224 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WAS
               DEPORTED
         (1) received (2) too much in benefits because (3) deported from the United States.
            Please read the rest of this letter carefully. In it, we explain the changes we made
            to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you were 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he was 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she was 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT225 – OVERPAYMENT ESTABLISHED DUE TO INCORRECT COMPUTATION, A LEGALLY DEFINED
               OVERPAYMENT OR TO RECOVER A SKELETON DUE PROCESS OVERPAYMENT
         (1) received (2) too much in benefits because the payment amount was incorrect. We
            corrected (3) record, which caused (4) benefit amount to decrease. Please read the
            rest of this letter carefully. In it, we explain the changes we made to (5) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (5) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT226 – OVERPAYMENT ESTABLISHED DUE TO SUBVERSIVE ACTIVITY
         (1) received (2) too much in benefits because (3) convicted of a crime against the
            United States. Please read the rest of this letter carefully. In it, we explain the
            changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you were 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he was 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she was 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT227 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY DID NOT HAVE A CHILD IN
               THEIR CARE
         (1) received (2) too much in benefits because (3) a child in (4) care who receives
            benefits from us. Please read the rest of this letter carefully. In it, we explain
            the changes we made to (5) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you no longer have 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he no longer has 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she no longer has 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (5) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT229 – OVERPAYMENT ESTABLISHED BECAUSE A WARRANT FOR THE BENEFICIARY’S ARREST
               EXISTS
         (1) received (2) too much in benefits. We should not have paid (3) because of a warrant
            for (4) arrest. Please read the rest of this letter carefully. In it, we explain the
            changes we made to (5) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         him 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (5) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT230 – OVERPAYMENT ESTABLISHED BECAUSE OF STATE OR FEDERAL ASSISTANCE
               
         (1) received (2) too much in benefits because (3) received State or Federal assistance.
            Please read the rest of this letter carefully. In it, we explain the changes we made
            to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT231 – OVERPAYMENT CAUSED BY REPRESENTATIVE PAYEE MISUSE OF
               BENEFITS
         (1) received (2) too much in benefits because (3) misused funds while acting as a
            representative payee. Please read the rest of this letter carefully. In it, we explain
            the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT232 – OVERPAYMENT CAUSED BY DISABILITY CESSATION
         (1) received (2) too much in benefits because we cannot pay benefits after (3) disability
            ends. Please read the rest of this letter carefully. In it, we explain the changes
            we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 4 
                        
                      | 
                     
                     
                         Number Holder’s Beneficiary Given Name (BGN) plus Beneficiary Last Name (BLN) (possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT234 – OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF PROVISIONAL BENEFITS ON A
               CLAIM THAT WAS LATER DENIED
         (1) received (2) too much in benefits because (3) you received temporary benefits
            while we were making a decision on (4) claim that we later denied. Please read the
            rest of this letter carefully. In it, we explain the changes we made to (5) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (5) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT235 – OVERPAYMENT ESTABLISHED DUE TO CROSS-BENEFIT ADJUSTMENT
         We moved (1) overpayment of (2) to (3) for collection. Please read the rest of this
            letter carefully. In it, we explain the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         another person's 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Number Holder’s Beneficiary Given Name (BGN) plus Beneficiary Last Name (BLN) (possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT236 – OVERPAYMENT ESTABLISHED DUE TO CHANGE IN THE AMOUNT OR COMMENCEMENT OF
               THE GOVERNMENT PENSION OFFSET
         (1) received (2) too much in benefits because we must offset (3) benefit payments
            due to (4) receipt of a government pension. Please read the rest of this letter carefully.
            In it, we explain the changes we made to (5) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (5) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT237 – OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF A PENSION BASED ON WORK NOT
               COVERED BY SOCIAL SECURITY TAXES
         (1) received (2) too much in benefits because (3) received a pension based on work
            not covered by Social Security taxes. Please read the rest of this letter carefully.
            In it, we explain the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 4 
                        
                      | 
                     
                     
                         Wage Earner’s Name 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT238 – OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF PAYMENTS AFTER CONFINEMENT TO
               A MENTAL INSTITUTION BECAUSE OF A COURT ORDER
         (1) received (2) too much in benefits because (3) received payments after being confined
            to an institution because of a court order. Please read the rest of this letter carefully.
            In it, we explain the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT239 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WAS AN ALIEN LIVING
               OUTSIDE THE UNITED STATES WHILE RECEIVING BENEFITS 
         (1) received (2) too much in benefits because (3) not a United States citizen and
            (4) outside the country for six months in a row. Please read the rest of this letter
            carefully. In it, we explain the changes we made to (5) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you are 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he is 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she is 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you were 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he was 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she was 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (5) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT240 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WORKED OUTSIDE THE US
               IN A JOB NOT COVERED UNDER SOCIAL SECURITY TAXES
         (1) received (2) too much in benefits because (3) worked outside the United States
            in a job not covered by United States Social Security taxes. Please read the rest
            of this letter carefully. In it, we explain the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT241 – OVERPAYMENT ESTABLISHED DUE TO PRISONER SUSPENSION
         (1) received (2) too much in benefits because of (3) criminal conviction and confinement
            in a correctional institution for more than 30 days. Please read the rest of this
            letter carefully. In it, we explain the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT242 – OVERPAYMENT ESTABLISHED DUE TO DEATH RECLAMATION, REPRESENTATIVE PAYEE
               ELECTRONIC FUNDS TRANSFER (EFT) AFTER DEATH OR REPRESENTATIVE PAYEE DEATH
               
         (1) received (2) too much in benefits because we cannot pay benefits for the month
            of death or later. Please read the rest of this letter carefully. In it, we explain
            the changes we made to (3) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT243 – OVERPAYMENT ESTABLISHED DUE TO PERMANENT DEDUCTIONS RESULTING FROM THE
               ANNUAL EARNINGS TEST
         (1) received (2) too much in benefits because of (3) work and earnings. Please read
            the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 4 
                        
                      | 
                     
                     
                         Null 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT244 – OVERPAYMENT ESTABLISHED DUE TO DEATH SUPER-ENDORSEMENT
         (1) received (2) too much in benefits because (3) signed and cashed a check for the
            month of death or later . Please read the rest of this letter carefully. In it, we
            explain the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT245 – OVERPAYMENT ESTABLISHED DUE TO A CHANGE IN MARITAL STATUS
         (1) received (2) too much in benefits because of a change in (3) marital status. Please
            read the rest of this letter carefully. In it, we explain the changes we made to (4)
            benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT246 – OVERPAYMENT ESTABLISHED DUE TO ENTITLEMENT TO WORKERS’ COMPENSATION,
               PUBLIC DISABILITY OR BOTH 
         (1) received (2) too much in benefits because of (3) receipt of workers’ compensation,
            public disability payments or both of these payments. Please read the rest of this
            letter carefully. In it, we explain the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT247 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY CONTINUED TO RECEIVE
               BENEFITS AFTER THE AGE OF 18
         (1) received (2) too much in benefits because we do not pay benefits once a student
            reaches age 18, unless he or she is a full time student elementary or high school
            student. Please read the rest of this letter carefully. In it, we explain the changes
            we made to (3) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT248 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY CONTINUED TO RECEIVE
               BENEFITS AFTER AGE 19 OR 22
         (1) received (2) too much in benefits because we do not pay benefits once a full-time
            student reaches age 19, unless (3) disabled or meet(s) an exception which allows benefits
            to continue:
         
         
            - 
               
                  •
                  
                     for 2 months after a student turns 19, or;
                     
                   
                
             
            - 
               
                  •
                  
                     until the end of the school term, whichever comes first.
                     
                   
                
             
         
         Please read the rest of this letter carefully. In it, we explain the changes we made
            to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you are 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he is 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she is 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT249 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY IS NO LONGER IN
               FULL-TIME SCHOOL ATTENDANCE
         (1) received (2) too much in benefits because we do not pay benefits once a student
            stops going to school full-time. Please read the rest of this letter carefully. In
            it, we explain the changes we made to (3) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT250 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY REFUSED TO ACCEPT
               VOCATIONAL REHABILITATION
         (1) received (2) too much in benefits because we should not have paid benefits when
            (3) refused vocational rehabilitation services. Please read the rest of this letter
            carefully. In it, we explain the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT252 – OVERPAYMENT ESTABLISHED DUE TO UNPAID ATTORNEY FEES
         (1) received (2) too much in benefits because of unpaid attorney’s fees. Please read
            the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT253 – OVERPAYMENT ESTABLISHED RAILROAD RETIREMENT BOARD EARNINGS WERE
               INCORRECTLY USED TO ESTABLISH THE BENEFICARY’S ENTITLEMENT
         (1) received (2) too much in benefits because (3) received incorrect payments from
            the Railroad Retirement Board. Please read the rest of this letter carefully. In it,
            we explain the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT254 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICARY WAS NOT A UNITED STATES
               (U.S.) CITIZEN OR LAWFULLY PRESENT IN THE U.S.
         (1) received (2) too much in benefits because (3) received payments even though (4)
            not a United States citizen or lawfully present in the U.S. Please read the rest of
            this letter carefully. In it, we explain the changes we made to (5) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you were 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he was 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she was 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (5) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT255 – OVERPAYMENT ESTABLISHED BECAUSE THE MONTH OF ENTITLEMENT WAS
               INCORRECT
         (1) received (2) too much in benefits because of a change in the month (3) benefits
            started. Please read the rest of this letter carefully. In it, we explain the changes
            we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT257 – OVERPAYMENT ESTABLISHED DUE TO MULTIPLE ENTITLEMENTS
         (1) received (2) too much in benefits because (3) received payments on two or more
            records for the same month(s). Please read the rest of this letter carefully. In it,
            we explain the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | Fill-in (2) | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT258 – OVERPAYMENT ESTABLISHED BECAUSE INSURED STATUS WAS NOT
               MET
         (1) received (2) too much in benefits because (3) worked long enough under Social
            Security to receive monthly benefits. Please read the rest of this letter carefully.
            In it, we explain the changes we made to (4) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you have not 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he has not 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she has not 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT259 – OVERPAYMENT ESTABLISHED BECAUSE THE BENFICIARY MISUSED FUNDS WHILE
               SERVING AS A REPRESENTATIVE PAYEE 
         (1) received (2) too much in benefits because (3) misused benefits that (4) received
            as the representative payee for another person. Please read the rest of this letter
            carefully. In it, we explain the changes we made to (5) benefits.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         You 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (4) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         he 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         she 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (5) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         your 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         his 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 3 
                        
                      | 
                     
                     
                         her 
                        
                      | 
                     
                  
               
            
          
         OPT302 – OVERPAYMENT TRANSFERRED FROM ANOTHER RECORD FOR A DUALLY
               ENTITLED BENEFICIARY
         We have determined that (1) (2) overpaid (3) on another record. We will recover this
            overpayment on this record.
         
         
            
               
                  
                  
               
               
                  
                  
                     
                     | 
                         Fill-in values: 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
               
               
                  
                  
                     
                     | 
                         Fill-in (1) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         you 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (2) 
                        
                      | 
                     
                     
                           
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 1 
                        
                      | 
                     
                     
                         is 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Choice 2 
                        
                      | 
                     
                     
                         are 
                        
                      | 
                     
                  
                  
                     
                     | 
                         Fill-in (3) 
                        
                      | 
                     
                     
                         Overpayment amount in the format $$$$$.¢¢ 
                        
                      |