TN 3 (05-92)

NL 00803.120 Completion of Fill-ins (4) Through (6) on the SSA-L8170-U3


1. Fill-in (4)

Fill-in (4) is in the paragraph under the caption “If We Don't Hear From You In The Next 30 Days” as follows:

“We plan to collect this overpayment from your SSI checks.    (4)    . If you ask for a waiver or appeal...”.

2. Fill-ins (5) and (6)

Fill-ins (5) and (6) are in the first bullet under the caption “How to Pay Us Back” as follows:

“As we said earlier, we plan to hold back    (5)    from your SSI check until you've paid us back.    (6)    .”


1. Fill-in (4)

See paragraph 2903 (NL 00804.260) for language for fill-in (4). When it will take more than 2 months to recover the overpayment, use the notice language that gives the month overpayment recovery will begin and the continuing recovery rate.

2. Fill-in (5)

Enter the proposed amount of recovery from fill-in (4). If you propose to hold back the entire SSI check because it is less than ten percent of the recipient's total income, enter the actual amount of the SSI check.

3. Fill-in (6)

Choose the appropriate fill-in from paragraph 2907 in NL 00804.260 based on the length of time needed to recover the overpayment.


Instructions for computing the 10 percent recovery rate and exceptions to this rule - SI 02220.015.

To Link to this section - Use this URL:
NL 00803.120 - Completion of Fill-ins (4) Through (6) on the SSA-L8170-U3 - 04/27/1992
Batch run: 01/27/2009