TN 24 (12-94)

NL 00804.260 Automated Overpayment Notice (AONS)

These paragraphs appear on the manual overpayment forms (i.e., SSA-L8170-U3, SSA-L8171-U3, SSA-L8172-U3). The paragraphs are listed in the order they should appear on the notice. In this chapter, “Situation Where Used:” only appears where an explanation is required.

2900. We are writing to let you know that we've paid (1) (2) too much Supplemental Security Income (SSI) money. The overpayment happened (3) . (4) overpaid (5) (6) (7) (8)

 

  1. Choice 1 - you

    Choice 2 - (Name of recipient)

     

  2. $$$.¢¢

     

  3. Choice 1 - in (Month/Year)

    Choice 2 - in (Month/Year) and (Month/Year)

    Choice 3 - from (Month/Year) through (Month/Year)

     

  4. Choice 1 - You were

    Choice 2 - She was

    Choice 3 - He was

     

  5. Choice 1 - because

    Choice 2 - for the following reasons.

    Choice 3 - for several reasons.

     

  6. Choice 1 - The first reason was because

    Choice 2 - The second reason was because

    Choice 3 - The third reason was because

    Choice 4 - Null

     

  7. Choice 1 - of your

    Choice 2 - of her

    Choice 3 - of his

    Choice 4 - of your spouse's

    Choice 5 - of her spouse's

    Choice 6 - of his spouse's

    Choice 7 - of your parent's

    Choice 8 - of her parent's

    Choice 9 - of his parent's

    Choice 10 - of your parents'

    Choice 11 - of her parents'

    Choice 12 - of his parents'

    Choice 13 - of (Name of essential person)'s

    Choice 14 - of (Name of essential person)'

    Choice 15 - of the

    Choice 16 - of an increase in your

    Choice 17 - of an increase in her

    Choice 18 - of an increase in his

    Choice 19 - of an increase in your spouse's

    Choice 20 - of an increase in her spouse's

    Choice 21 - of an increase in his spouse's

    Choice 22 - of an increase in your parent's

    Choice 23 - of an increase in her parent's

    Choice 24 - of an increase in his parent's

    Choice 25 - of an increase in your parents'

    Choice 26 - of an increase in her parents'

    Choice 27 - of an increase in his parents'

    Choice 28 - of an increase in (Name of essential person)'s

    Choice 29 - of an increase in (Name of essential person)'

    Choice 30 - of an increase in the

    Choice 31 - you were

    Choice 32 - she was

    Choice 33 - he was

    Choice 34 - you

    Choice 35 - she

    Choice 36 - he

    Choice 37 - your

    Choice 38 - her

    Choice 39 - his

    Choice 40 - your spouse was

    Choice 41 - her spouse was

    Choice 42 - his spouse was

    Choice 43 - Null

     

  8. Choice 1 - Social Security benefits.

    Choice 2 - Black Lung benefits.

    Choice 3 - Veterans benefits.

    Choice 4 - Railroad benefits.

    Choice 5 - assistance payments based on need.

    Choice 6 - help you got to pay the cost of your food, clothing or shelter.

    Choice 7 - help she got to pay the cost of her food, clothing or shelter.

    Choice 8 - help he got to pay the cost of his food, clothing or shelter.

    Choice 9 - pension.

    Choice 10 - pensions.

    Choice 11 - support from your parent.

    Choice 12 - support from her parent.

    Choice 13 - support from his parent.

    Choice 14 - worker's compensation.

    Choice 15 - income from interest, dividends, rents or royalties.

    Choice 16 - gifts, prizes, cash or special income.

    Choice 17 - share of your sponsor's income.

    Choice 18 - share of her sponsor's income.

    Choice 19 - share of his sponsor's income.

    Choice 20 - share of your sponsor's and your sponsor's spouse's income.

    Choice 21 - share of her sponsor's and her sponsor's spouse's income.

    Choice 22 - share of his sponsor's and his sponsor's spouse's income.

    Choice 23 - wages.

    Choice 24 - income from being self-employed.

    Choice 25 - living in a public institution.

    Choice 26 - outside the United States.

    Choice 27 - resources were more than a person could own and still get SSI.

    Choice 28 - did not file for other benefits.

    Choice 29 - refused training that may help you go to work.

    Choice 30 - refused training that may help her go to work.

    Choice 31 - refused training that may help him go to work.

    Choice 32 - refused treatment for drug addiction.

    Choice 33 - refused treatment for alcoholism.

    Choice 34 - refused treatment for drug addiction and alcoholism.

    Choice 35 - not a citizen of the United States or legally allowed to stay in the United States.

    Choice 36 - dis not return an SSI check after you told us to stop sending them.

    Choice 37 - did not return an SSI check after she told us to stop sending them.

    Choice 38 - did not return an SSI check after he told us to stop sending them.

    Choice 39 - living in a medical care facility.

    Choice 40 - getting food and shelter in someone else's home or apartment.

    Choice 41 - paid after your eligibility for payments based on blindness ended.

    Choice 42 - paid after her eligibility for payments based on blindness ended.

    Choice 43 - paid after his eligibility for payments based on blindness ended.

    Choice 44 - paid after your eligibility for payments based on disability ended.

    Choice 45 - paid after her eligibility for payments based on disability ended.

    Choice 46 - paid after his eligibility for payments based on disability ended.

    Choice 47 - not blind.

    Choice 48 - not disabled.

    Choice 49 - help your spouse got to pay the cost of food, clothing and shelter.

    Choice 50 - help her spouse got to pay the cost of food, clothing and shelter.

    Choice 51 - help his spouse got to pay the cost of food, shelter.

    Choice 52 - Null

     

2901. (1) Later in this letter, we'll give you a detailed explanation of (2) (3) overpayment.

 

  1. Choice 1 - This new overpayment is in addition to the old overpayment we are now collecting. You still owe ($$$.¢¢) from the old overpayment.

    Choice 2 - This new overpayment is in addition to the old overpayment we are now collecting. She still owes ($$$.¢¢) from the old overpayment.

    Choice 3 - This new overpayment is in addition to the old overpayment we are now collecting. He still owes ($$$.¢¢) from the old overpayment.

    Choice 4 - This overpayment is in addition to the advance payment we are now collecting. You still owe ($$$.¢¢) from the advance payment.

    Choice 5 - This overpayment is in addition to the advance payment we are now collecting. She still owes ($$$.¢¢) from the advance payment.

    Choice 6 - This overpayment is in addition to the advance payment we are now collecting. He still owes ($$$.¢¢) from the advance payment.

    Choice 7 - This new overpayment is in addition to the old overpayment and the advance payment we are now collecting. You still owe ($$$.¢¢)

    Choice 8 - This new overpayment is in addition to the old overpayment and the advance payment we are now collecting. She still owes ($$$.¢¢) from the old overpayment and the advance payment.

    Choice 9 - This new overpayment is in addition to the old overpayment and the advance payment we are now collecting. He still owes ($$$.¢¢) from the old overpayment and the advance payment.

    Choice 10 - This new overpayment is in addition to the old overpayment already on your record. You still owe ($$$.¢¢) from the old overpayment.

    Choice 11 - This new overpayment is in addition to the old overpayment already on her record. She still owes ($$$.¢¢) from the old overpayment.

    Choice 12 - This new overpayment is in addition to the old overpayment already on his record. He still owes ($$$.¢¢) from the old overpayment.

    Choice 13 - This overpayment is in addition to the advance payment made to you. You still owe ($$$.¢¢) from the advance payment.

    Choice 14 - This overpayment is in addition to the advance payment made to her. She still owes ($$$.¢¢) from the advance payment.

    Choice 15 - This overpayment is in addition to the advance payment made to him. He still owes ($$$.¢¢) from the advance payment.

    Choice 16 - This new overpayment is in addition to the old overpayment and the advance payment already on your record. You still owe ($$$.¢¢

    Choice 17 - This new overpayment is in addition to the old overpayment and the advance payment already on her record. She still owes ($$$.¢¢) from the old overpayment and the advance payment.

    Choice 18 - This new overpayment is in addition to the old overpayment and the advance payment already on his record. He still owes ($$$.¢¢) from the old overpayment and the advance payment.

    Choice 19 - Null

     

  2. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  3. Choice 1 - new

    Choice 2 - Null

     

2941. NOTE: This paragraph replaces 2902.

(1) must pay us back unless we decide (2) shouldn't have to pay us back or we're wrong about the overpayment. If you think (3) shouldn't have to pay us back or think we're wrong, you can:

 

  • Ask for a waiver,

  • Ask for an appeal, or

  • Do both.

Fill-ins:

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  2. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  3. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

2903. Situation Where Used:

Used only on the SSA-L8170. Informs the overpaid individual that we intend to collect overpayment via monthly check adjustment.

If We Don't Hear From You In The Next 30 Days

We plan to collect this (1) overpayment from (2) SSI checks. (3) .

If you ask for waiver or appeal in the next 30 days, we won't (4) until we decide (5) case.

 

  1. Choice 1 - new

    Choice 2 - Null

     

  2. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  3. Choice 1 - We'll hold back ($$$.¢¢) each month starting with (Month/Year) until you have paid us back.

    Choice 2 - We'll hold back ($$$.¢¢) each month starting with (Month /Year) until she has paid us back.

    Choice 3 - We'll hold back ($$$.¢¢) each month starting with (Month /Year) until he has paid us back.

    Choice 4 - We'll hold back ($$$.¢¢) in (Month/Year) to collect the overpayment.

    Choice 5 - We'll hold back ($$$.¢¢) in (Month/Year) and ($$$. ¢¢) in (Month/Year) to collect the overpayment.

    Choice 6 - We'll hold back your check each month starting with (Month/ Year) until you have paid us back.

    Choice 7 - We'll hold back her check each month starting with (Month/Year) until she has paid us back.

    Choice 8 - We'll hold back his check each month starting with (Month/Year) until he has paid us back.

    Choice 9 - We'll hold back your check for (Month/Year) to collect the overpayment.

    Choice 10 - We'll hold back her check for (Month/Year) to collect the overpayment.

    Choice 11 - We'll hold back his check for (Month/Year) to collect the overpayment.

    Choice 12 - We'll hold back your checks for (Month/Year) and (Month/

    Choice 13 - We'll hold back her checks for (Month/Year) and (Month/Year) to collect the overpayment.

    Choice 14 - We'll hold back his checks for (Month/Year) and (Month/Year) to collect the overpayment.

    Choice 15 - We'll hold back your check for (Month/Year) and ($$$.¢ ¢) in (Month/Year) to collect the overpayment.

    Choice 16 - We'll hold back her check for (Month/Year) and ($$$.¢ ¢) in (Month/Year) to collect the overpayment.

    Choice 17 - We'll hold back his check for (Month/Year) and ($$$.¢ ¢) in (Month/Year) to collect the overpayment.

    Choice 18 - We'll continue holding back your check each month until you have paid back the old and the new overpayments.

    Choice 19 - We'll continue holding back her check each month until she has paid back the old and the new overpayments.

    Choice 20 - We'll continue holding back his check each month until he has paid back the old and the new overpayments.

    Choice 21 - We'll continue holding back ($$$.¢¢) each month until you have paid back the old and the new overpayments.

    Choice 22 - We'll continue holding back ($$$.¢¢) each month until she has paid back the old and the new overpayments.

    Choice 23 - We'll continue holding back ($$$.¢¢) each month until he has paid back the old and the new overpayments.

    Choice 24 - We'll change the amount we hold back each month from ($$$. ¢ ¢) to ($$$.¢¢). This will start in (Month/Year). It will continue until you have paid back the old and the new overpayments.

    Choice 25 - We'll change the amount we hold back each month¢¢) to ($$$.¢¢). This will start in (Month/Year). It will continue until she has paid back the old and the new overpayments.

    Choice 26 - We'll change the amount we hold back each month from ($$$. ¢ ¢) to ($$$.¢¢). This will start in (Month/Year). It will continue until he has paid back the old and the new overpayments.

    Choice 27 - We will collect the advance payment first. Then, we will begin collecting the overpayment from your check.

    Choice 28 - We will collect the advance payment first. Then, we will begin collecting the overpayment from her check.

    Choice 29 - We will collect the advance payment first. Then, we will begin collecting the overpayment from his check.

     

  4. Choice 1 - start collecting the new overpayment

    Choice 2 - change your check

    Choice 3 - change her check

    Choice 4 - change his check

     

  5. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

2942. NOTE: This paragraph replaces 2904.

If You Think (1) Shouldn't Have To Pay Us Back

(2) may not have to pay us back. Sometimes we can waive an us back. We can do this if both of the following are true.

  • It wasn't (4) fault that (5) got too much SSI money.

    AND

  • Paying us back would mean (6) can't pay (7) bills for food, clothing, housing or medical care, or it would be unfair for some other reason.

If you think these are true about (8) , contact any Social Security office. You can ask for a waiver any time by asking your Social Security office to fill out the waiver form. The waiver form number is SSA-632. We won't collect the overpayment while we decide if we can waive it.

 

  1. Choice 1 - You

    Choice 2 - (Name of recipient)

     

  2. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  3. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  4. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  5. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  6. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  7. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  8. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

2905. Situation Where Used:

There is representative payee data on the new record. (This language is found on the SSA-L8176-U2 which is a manual notice that goes to the representative payee.)

Special Message for Representative Payees

If the overpayment is not repaid by (1) or from (2) funds, we will ask you to repay it from your own money. If (3) begins to repay us, but stops before the overpayment is will ask you for any amount remaining. But we won't ask you to repay us if both of the following are true.

  • You used the SSI check(s) for (4) needs.

    AND

  • It was not your fault that (5) was overpaid.

Please let us know as soon as possible if you think both of these facts are true.

In addition, we won't ask you to repay us from your own money for any month(s) of overpayment in which you were not the representative payee. If you were not the payee for any of the overpayment months, please tell us. If there was a payee before you, and you have that person's name and address, please give it to us. You can contact any Social Security office.

 

  1. (Name of recipient)

     

  2. Choice 1 - her

    Choice 2 - his

     

  3. Choice 1 - she

    Choice 2 - he

     

  4. Choice 1 - her

    Choice 2 - his

     

  5. Choice 1 - she

    Choice 2 - he

     

2906. Situation Where Used:

Appeal rights. Appears only on the SSA-L8170 version of the overpayment forms.

Do You Think We're Wrong?

If you think we're wrong, you have the right to appeal. We'll correct mistakes. We'll look at any new facts you have.

 

  • You have 60 days to ask for an appeal. If you ask in the next 30 days, we won't change (1) case.

  • Both the 30 day and the 60 day periods start the day after you get this letter.

  • You'll have to have a good reason for waiting more than 60 days to ask for an appeal.

  • To appeal, you must fill out a form called “Request for Reconsideration.” The form number is SSA-561. To get this form, contact one of our offices. We can help you fill out the form.

How To Appeal

There are three ways to appeal. You can pick the one you want. If you meet with us in person, it may help us decide (2) case.

 

  • Case Review . You have a right to review the facts in (3) file. You can give us more facts to add to (4) won't meet with the person who decides (6) case.

     

  • Informal Conference . You'll meet with the person who decides (7) case. You can tell that person why you think you're right. You can give us more facts to help prove you're right. You can bring other people to help explain (8) case.

     

  • Formal Conference . This is a meeting like an informal conference. The difference is we can make people come to help prove you're right. We can make them bring important papers about (9) case, even if they don't want to help you. You can question these people at your meeting.

If You Want Help With Your Appeal

You may want help from a friend, lawyer or someone else. There are groups that can find you a lawyer. Some can give you a free lawyer. We can give you the names of these groups.

 

  1. Choice 1 - your check until we decide your

    Choice 2 - her check until we decide her

    Choice 3 - his check until we decide his

     

  2. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  3. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  4. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  5. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  6. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  7. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  8. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  9. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

2907. Situation Where Used:

Appears only on the SSA-L8170. Individual is in current pay status.

How To Pay Us Back

There are two ways you can pay us back.

  • As we said earlier, we plan to hold back money from (1) SSI check. (2) (3) Ten percent is the most we can hold back without your consent. Contact us if you want a different amount held back.

    OR

  • Another way to pay us back is to send us a check or money order for the full amount of (4) (5) overpayment of (6) . Paying us this way is voluntary. Make your check or money order out to the Social Security Administration. Be sure to put (7) Social Security number on it. Please use the enclosed envelope to mail the check or money order to us. Also, be sure to enclose the payment stub with your check or money order.

Fill-ins:

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. Choice 1 - We'll hold back ($$$.¢¢) each month starting with (Month/Year) until you have paid us back.

    Choice 2 - We'll hold back ($$$.¢¢) each month starting with (Month /Year) until she has paid us back.

    Choice 3 - We'll hold back ($$$.¢¢) each month starting with (Month /Year) until he has paid us back.

    Choice 4 - We'll hold back ($$$.¢¢) in (Month/Year) to collect the overpayment.

    Choice 5 - We'll hold back ($$$.¢¢) in (Month/Year) and ($$$ ¢¢) in Month/Year) to collect the overpayment.

    Choice 6 - We'll hold back your check each month starting with (Month/ Year) until you have paid us back.

    Choice 7 - We'll hold back her check each month starting with (Month/Year) until she has paid us back.

    Choice 8 - We'll hold back his check each month starting with (Month/Year) until he has paid us back.

    Choice 9 - We'll hold back your check for (Month/Year) to collect the overpayment.

    Choice 10 - We'll hold back her check for (Month/Year) to collect the overpayment.

    Choice 11 - We'll hold back his check for (Month/Year) to collect the overpayment.

    Choice 12 - We'll hold back your checks for (Month/Year) and (Month/ Year) to collect the overpayment.

    Choice 13 - We'll hold back her checks for (Month/Year) and (Month/Year) to collect the overpayment.

    Choice 14 - We'll hold back his checks for (Month/Year) and (Month/Year) to collect the overpayment.

    Choice 15 - We'll hold back your check for (Month/Year) and ($$$.¢ ¢) in (Month/Year) to collect the overpayment.

    Choice 16 - We'll hold back her check for (Month/Year) and ¢) in (Month/Year) to collect the overpayment.

    Choice 17 - We'll hold back his check for (Month/Year) and ($$$.¢ ¢) in (Month/Year) to collect the overpayment.

    Choice 18 - We'll continue holding back your check each month until you have paid back the old and the new overpayments.

    Choice 19 - We'll continue holding back her check each month until she has paid back the old and the new overpayments.

    Choice 20 - We'll continue holding back his check each month until he has paid back the old and the new overpayments.

    Choice 21 - We'll continue holding back ($$$.¢¢) each month until you have paid back the old and the new overpayments.

    Choice 22 - We'll continue holding back ($$$.¢¢) each month until she has paid back the old and the new overpayments.

    Choice 23 - We'll continue holding back ($$$.¢¢) each month until he has paid back the old and the new overpayments.

    Choice 24 - We'll change the amount we hold back each month from ($$$. ¢ ¢) to ($$$.¢¢). This will start in (Month/Year). It will continue until you have paid back the old and the new overpayments.

    Choice 25 - We'll change the amount we hold back each month from ($$$. ¢ ¢) to ($$$.¢¢). This will start in (Month/Year). It will continue until she has paid back the old and the new overpayments.

    Choice 26 - We'll change the amount we hold back each month from ($$$. ¢ ¢) to ($$$.¢¢). This will start in (Month/Year). It will continue until he has paid back the old and the new overpayments.

    Choice 27 - We will collect the advance payment first. Then, we will begin

    Choice 28 - We will collect the advance payment first. Then we will begin collecting the overpayment from her check.

    Choice 29 - We will collect the advance payment first. Then, we will begin collecting the overpayment from his check.

     

  3. Choice 1 - This is not more than 10 percent of your total income.

    Choice 2 - This is not more than 10 percent of her total income.

    Choice 3 - This is not more than 10 percent of his total income.

    Choice 4 - The amount of your SSI check is less than 10 percent of your total income.

    Choice 5 - The amount of her SSI check is less than 10 percent of her total income.

    Choice 6 - The amount of his SSI check is less than 10 percent of his total income.

    Choice 7 - When we begin collecting the overpayment, we will collect no more than 10 percent of your total income.

    Choice 8 - When we begin collecting the overpayment, we will collect no more than 10 percent of her total income.

    Choice 9 - When we begin collecting the overpayment, we will collect no more than 10 percent of his total income.

     

  4. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  5. Choice 1 - new

    Choice 2 - Null

(6) $$$.¢¢

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

2908. Situation Where Used:

Recipient is in a medical care facility where Medicaid pays for more than half the cost of care and is currently receiving a monthly SSI check. We will not reduce her/his check to recover the overpayment while in the medical care facility. This paragraph appears only on the SSA-8170 and the SSA-L8171.

We Will Not Reduce (1) SSI Check

Usually when a person is getting an SSI check, we withhold money from the check to repay an overpayment. But we will not do this while (2) :

 

  • In a medical care facility,

    AND

  • Medicaid is paying for more than half the cost of (3) care.

If either of the above things change, and (4) still withholding money from (6) SSI check.

 

  1. Choice 1 - Your

    Choice 2 - Her

    Choice 3 - His

     

  2. Choice 1 - you are

    Choice 2 - she is

    Choice 3 - he is

     

  3. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  4. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  5. Choice 1 - have

    Choice 2 - has

     

  6. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

2909. Situation Where Used:

and does not receive title II.

How To Pay Us Back

There are two ways you can pay us back.

 

  • You can send us a check or money order for the full amount of (1) (2) overpayment of (3) . Make your check or money order out to the Social Security Administration. Be sure to put (4) Social Security number on it. Please use the enclosed envelope to mail the check or money order to us. Also, be sure to enclose the payment stub with your check or money order.

    OR

  • If you can't send us the full amount now, send as much as you can. Then contact any Social Security office. You can pay the rest of the money (5) by making monthly payments.

If you can't pay us in full, please contact us by (6) . You'll need to tell us how you plan to pay us back.

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. Choice 1 - new

    Choice 2 - Null

     

  3. $$$.¢¢

     

  4. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  5. Choice 1 - you owe

    Choice 2 - she owes

    Choice 3 - he owes

     

  6. (Month/Day/Year)

     

2910. Situation Where Used:

Appears only on the SSA-L8172. Individual is in nonpayment status but does receive title II. Offers the option of recovery by making monthly payments or by cross-program recovery.

How To Pay Us Back

There are three ways you can pay us back.

 

  • You can send us a check or money order for the full amount of (1) (2) overpayment of (3) . Make your check or money order out to the Social Security Administration. Be sure to put (4) Social Security number on it. Please use the enclosed envelope to mail the check or money order to us. Also, be sure to enclose the payment stub with your check or money order.

    OR

  • If you can't send us the full amount now, send as much as you can. Then contact any Social Security office. You can pay the rest of the money (5) by making monthly payments.

    OR

  • You can ask us to hold back part of (6) Social Security benefit until (7) paid us back. This way of paying us back is voluntary . If you ask us to do this you can tell us to stop whenever you want. (8) Social Security benefits won't change unless you choose to pay us back this way.

If you can't pay us in full, please contact us by (9) . You'll need to tell us how you plan to pay us back.

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. Choice 1 - new

    Choice 2 - Null

     

  3. $$$.¢¢

     

  4. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  5. Choice 1 - you owe

    Choice 2 - she owes

    Choice 3 - he owes

     

  6. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  7. Choice 1 - you have

    Choice 2 - she has

    Choice 3 - he has

     

  8. Choice 1 - Your

    Choice 2 - Her

    Choice 3 - His

     

  9. (Month/Day/Year)

     

2911. Situation Where Used:

Appeal rights. Appears only on the SSA-L8171 and SSA-L8172.

Do You Think We're Wrong?

If you think we're wrong, you have the right to appeal. We'll correct mistakes. We'll look at any new facts you have.

 

  • You have 60 days to ask for an appeal.

  • The 60 days start the day after you get this letter.

  • You'll have to have a good reason for waiting more than 60 days to ask

  • To appeal, you must fill out a form called “Request for Reconsideration.” The form number is SSA-561. To get this form, contact one of our offices. We can help you fill out the form.

How To Appeal

There are three ways to appeal. You can pick the one you want. If you meet with us in person, it may help us decide (1) case .

 

  • Case Review . You have a right to review the facts in (2) file. You can give us more facts to add to (3) file. Then we'll decide (4) case again. You won't meet with the person who decides (5) case.

     

  • Informal Conference . You'll meet with the person who decides (6) case. You can tell that person why you think you're right. You can give us more facts to help prove you're right. You can bring other people to help explain (7) case.

     

  • Formal Conference . This is a meeting like an informal conference. The difference is we can make people come to help prove you're right. We can make them bring important papers about (8) case, even if they don't want to help you. You can question these people at your meeting.

If You Want Help With Your Appeal

You may want help from a friend, lawyer or someone else. There are groups that give you the names of these groups.

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  3. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  4. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  5. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  6. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  7. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  8. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

2912. For Your Information(CAPTION)

 

2920. Enclosures:

—A Detailed Explanation of (1) Overpayment

—Payment Stub

—Refund Envelope

 

  1. Choice 1 - Your

    Choice 2 - Her

    Choice 1 - His

     

2921. A Detailed Explanation of (1) Overpayment (CAPTION-TITLE)

 

  1. Choice 1 - Your

    Choice 2 - Her

    Choice 3 - His

     

2922. Overpayment Summary(CAPTION)

2923. Situation Where Used:

All months in the overpayment period are new overpayments and are not windfall months.

(1) overpaid (2) . The following table shows how (3) payment changed each month. The first column lists the month(s) we paid (4) incorrectly. The next column shows the amount we paid (5) for each month. The last column, “Amount for Each Month,” shows the amount we should have paid (6) for each month.

(7)

MonthAmount We Paid Each MonthCorrect Amount for Each Month
(8) (9) (10)

 

  1. Choice 1 - You were

    Choice 2 - She was

    Choice 3 - He was

(2) $$$.¢¢

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  3. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  4. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  5. Choice 1 - The SSI we paid you included some payments we made for your State. We show your total SSI below, and then the part of this money that is from your State.

    Choice 2 - The SSI we paid her included some payments we made for her State. We show her total SSI below, and then the part of this money that is from her State.

    Choice 3 - The SSI we paid him included some payments we made for his State. We show his total SSI below, and then the part of this money that is from his State.

    Choice 4 - Null

     

  6. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) and (Month/Year)

    Choice 3 - (Month) through (Month/Year)

    Choice 4 - Null

  7. Choice 1 - $$$.¢¢

    Choice 2 - $$$.¢¢($$$.¢¢from (State))

    Choice 3 - Null

     

  8. Choice 1 - $$$.¢¢

    Choice 2 - $$$.¢¢($$$.¢¢from (State))

    Choice 3 - Null

     

2924. Situation Where Used:

At least one of the overpayment months in the overpayment period has a prior overpayment (TOP) on the old record and/or at least one of the overpayment months in the overpayment period is in a title II windfall period.

(1) overpaid (2) . The following table shows how (3) payment changed each month. The first column lists the month(s) we paid (4) incorrectly. The next column shows the incorrect amount for each month. The last column, “Correct Amount for Each Month,” shows the amount we should have paid (5) for each month.

(6)

MonthIncorrect Amount For Each MonthCorrect Amount For Each Month
(7) (8) (9)

 

  1. Choice 1 - You were

    Choice 2 - She was

    Choice 3 - He was

(2) $$$.¢¢

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  3. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  4. Choice 1 - The SSI we paid you included some payments we made for your State. We show your total SSI below, and then the part of this money that is from your State.

    Choice 2 - The SSI we paid her included some payments we made for her State. We show her total SSI below, and then the part of this money that is from her State.

    Choice 3 - The SSI we paid him included some payments we made for his State. We show his total SSI below, and then the part of this money that is from his State.

    Choice 4 - Null

     

  5. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) and (Month/Year)

    Choice 3 - (Month/Year) through (Month/Year)

    Choice 4 - Null

     

  6. Choice 1 - $$$.¢¢

    Choice 2 - $$$.¢¢($$$.¢¢from (State))

    Choice 3 - Null

     

  7. Choice 1 - $$$.¢¢

    Choice 2 - $$$.¢¢($$$.¢¢from (State))

    Choice 3 - Null

     

2925. Situation Where Used:

An overpayment addressed in a prior overpayment notice has an additional overpayment computed.

This notice changes the decision we sent you before about (1) overpayment for (2) (3)

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  2. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) through (Month/Year)

     

  3. Choice 1 - ,

    Choice 2 - and

    Choice 3 - .

     

2926. Why (1) Overpaid(CAPTION)

 

  1. Choice 1 - You Were

    Choice 2 - She Was

    Choice 3 - He Was

     

2927. Situation Where Used:

Recipient is overpaid due to an income change.

For the month(s) listed below, (1) income on our records was wrong. (2)

Under “Type of Income,” we list only the income which we corrected on our records. Under the column called “Amount We Used,” we show the amount we used earlier to figure (3) payment. Under the column called “Correct Amount,” we show the amount we should have used to figure (4) payment. Please check that column against (5) records. If the amount is wrong, the amount of (6) overpayment is wrong.

MonthAmount We UsedCorrect AmountType of
(7) (8) (9) (10) (11)
(12)    

 

  1. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

    Choice 4 - the

     

  2. Choice 1 - Because we didn't know about all your income, we paid you too much SSI.

    Choice 2 - Because we didn't know about all her income, we paid her too much SSI.

    Choice 3 - Because we didn't know about all his income, we paid him too much SSI.

    Choice 4 - Because we didn't know about all the income, we paid you too much SSI.

    Choice 5 - Because we didn't know about all the income, we paid her too much SSI.

    Choice 6 - Because we didn't know about all the income, we paid him too much SSI.

    Choice 7 - Null

     

  3. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  4. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  5. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  6. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  7. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) and (Month/Year)

    Choice 3 - (Month/Year) through (Month/Year)

(8) $$$.¢¢

(9) $$$.¢¢

 

  1. Choice 1 - Your

    Choice 2 - Her

    Choice 3 - His

    Choice 4 - Your spouse's

    Choice 5 - Her spouse's

    Choice 6 - His spouse's

    Choice 7 - Your parent's

    Choice 8 - Her parent's

    Choice 9 - His parent's

    Choice 10 - Your parents'

    Choice 11 - Her parents'

    Choice 12 - His parents'

    Choice 13 - (Name of essential person)'s

    Choice 14 - (Name of essential persons)'

    Choice 15 - Null

     

  2. Choice 1 - Social Security benefits

    Choice 2 - Black Lung benefits

    Choice 3 - Veterans Administration benefits

    Choice 4 - Railroad Retirement benefits

    Choice 5 - Veterans Administration benefits based on need

    Choice 6 - assistance payments based on need

    Choice 7 - food, clothing or shelter

    Choice 8 - Military pension

    Choice 9 - civil service pension

    Choice 10 - support from your parent

    Choice 11 - support from her parent

    Choice 12 - support from his parent

    Choice 13 - pension from a former job

    Choice 14 - worker's compensation

    Choice 15 - interest, dividends, rents or royalties

    Choice 16 - gifts, prizes, cash or special income

    Choice 17 - Your sponsor's income which we count as yours

    Choice 18 - Her sponsor's income which we count as hers

    Choice 19 - His sponsor's income which we count as his

    Choice 20 - Your sponsor's and sponsor's spouse's income which we count as yours

    Choice 21 - Her sponsor's and sponsor's spouse's income which we count as hers

    Choice 22 - His sponsor's and sponsor's spouse's income which we count as his

    Choice 23 - wages

    Choice 24 - income from being self-employed

    Choice 25 - food and shelter in someone else's home or apartment

     

  3. Choice 1 - We use income from 2 months earlier when we figure your SSI payment for a month. You should remember this when comparing the above tables. For example, we used income from (Month/Year) to figure your payment for (Month/Year).

    Choice 2 - We use income from 2 months earlier when we figure her SSI payment for a month. You should remember this when comparing the above tables. For example, we used income from (Month/Year) to figure her payment for (Month/Year).

    Choice 3 - We use income from 2 months earlier when we figure his SSI payment for a month. You should remember this when comparing the above tables. For example, we used income from (Month/Year) to figure his payment for (Month/Year).

    Choice 4 - Null

     

2928. Situation Where Used:

an SSA-L8171.

(1) could not get SSI because all of these facts below were true.

(2) in an institution run by the Federal, State, or local government. This includes some hospitals, nursing homes, other care facilities or prisons.

AND

(3) lived there at least 1 full month.

AND

•If (4) had Medicaid, it did not pay for more than half the cost of (5) care.

As a result, (6) overpaid for (7) . (8)

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  2. Choice 1 - You were

    Choice 2 - She was

    Choice 3 - He was

     

  3. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

  4. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  5. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  6. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  7. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) and (Month/Year)

    Choice 3 - (Month/Year) through (Month/Year)

     

  8. Choice 1 - You were eligible for SSI again on (Month/Day/Year), the day that you left the institution.

    Choice 2 - She was eligible for SSI again on (Month/Day/Year), the day that she left the institution.

    Choice 3 - He was eligible for SSI again on (Month/Day/Year), the day that he left the institution.

    Choice 4 - Null

     

2929. Situation Where Used:

Recipient was living outside the U.S. for a full calendar month

(1) could not get SSI because (2) outside the United States. For SSI, the United States is:

•One of the 50 States;

OR

•The District of Columbia;

OR

•The Northern Mariana Islands.

(3)

As a result, (4) overpaid for (5) .

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  2. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  3. Choice 1 - You were not eligible for SSI again until the 31st day after you were back in the United States. The 31st day was (Month/Day/Year).

    Choice 2 - She was not eligible for SSI again until the 31st day after she was back in the United States. The 31st day was (Month/Day/Year).

    Choice 3 - He was not eligible for SSI again until the 31st was back in the United States. The 31st day was (Month/Day/Year).

    Choice 4 - Null

     

  4. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  5. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) and (Month/Year)

    Choice 3 - Month/Year) through (Month/Year)

     

2930. Situation Where Used:

Recipient has excess resources.

(1) could not get SSI since the value of (2) resources was more than the SSI limit. As a result, (3) overpaid (4) (5) (6) (7) the limit on the value of the things (8) owned which we included as (9) resources (10) (11) .

(12) (13) (14) (15) .

Resources may include cash, money in bank accounts, stocks, bonds, land or housing other than the home (16) in, certain kinds of life tell you which things we include as resources.

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  2. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  3. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  4. Choice 1 - for (Month/Year)

    Choice 2 - from (Month/Year) through (Month/Year)

    Choice 3 - in (Month/Year)

     

  5. Choice 1 - ,

    Choice 2 - and

    Choice 3 - .

     

  6. Choice 1 - For (Month/Year)

    Choice 2 - Before January 1985

    Choice 3 - In (Month/Year) or In (Year)

    Choice 4 - (Month/Year)

     

  7. Choice 1 - ,

    Choice 2 - and

    Choice 3 - .

     

  8. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

    Choice 4 - you and your spouse

    Choice 5 - she and her spouse

    Choice 6 - he and his spouse

    Choice 7 - you and your parent

    Choice 8 - she and her parent

    Choice 9 - he and his parent

    Choice 10 - you and your parents

    Choice 11 - she and her parents

    Choice 12 - he and his parents

    Choice 13 - you and (Name of essential person)

    Choice 14 - she and (Name of essential person)

    Choice 15 - he and (Name of essential person)

    Choice 16 - you, your spouse and (Name of essential person)

    Choice 17 - she, her spouse and (Name of essential person)

    Choice 18 - he, his spouse and (Name of essential person)

    Choice 19 - you, your parent and (Name of essential person)

    Choice 20 - she, her parent and (Name of essential person)

    Choice 21 - he, his parent and (Name of essential person)

    Choice 22 - you and your sponsor

    Choice 23 - she and her sponsor

    Choice 24 - he and his sponsor

    Choice 25 - you, your sponsor and the spouse of your sponsor

    Choice 26 - she, her sponsor and the spouse of her sponsor

    Choice 27 - he, his sponsor and the spouse of his sponsor

    Choice 28 - you, your spouse and your sponsor

    Choice 29 - she, her spouse and her sponsor

    Choice 30 - he, his spouse and his sponsor

    Choice 31 - you, your spouse, your sponsor and the spouse of her sponsor

    Choice 32 - she, her spouse, her sponsor and the spouse of her sponsor

    Choice 33 - he, his spouse, his sponsor and the spouse of his sponsor

    Choice 34 - you, your parent and your sponsor

    Choice 35 - she, her parent and her sponsor

    Choice 36 - he, his parent and his sponsor

    Choice 37 - you, your parent, your sponsor and the spouse of your sponsor

    Choice 38 - she, her parent, her sponsor and the spouse of her sponsor

    Choice 39 - he, his parent, his sponsor and the spouse of his sponsor

    Choice 40 - you, your parents and your sponsor

    Choice 41 - she, her parents and her sponsor

    Choice 42 - he, his parents and his sponsor

    Choice 43 - you, your parents, your sponsor and the spouse of your sponsor

    Choice 44 - she, her parents, her sponsor and the spouse of her sponsor

    Choice 45 - he, his parents, his sponsor and the spouse of his sponsor

  9. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  10. Choice 1 - is

    Choice 2 - was

     

  11. $$$.¢¢

     

  12. Choice 1 - For (Month/Year)

    Choice 2 - In (Month/Year)

    Choice 3 - (Month/Year)

    Choice 4 - Null

     

  13. Choice 1 - ,

    Choice 2 - and

    Choice 3 - Null

     

  14. Choice 1 - the limit is

    Choice 2 - the limit was

    Choice 3 - Null

     

  15. Choice 1 - $$$.¢¢

    Choice 2 - Null

     

  16. Choice 1 - you live

    Choice 2 - she lives

    Choice 3 - he lives

     

2931. Situation Where Used:

Recipient did not file the required application or take necessary steps to obtain other benefits or payments.

We wrote to you about filing for money (1) may be able to get. We told you that (2) must file for this money in order to get SSI.

(3) did not file within 30 days after we told (4) to file. Because of this, (5) could not get SSI starting with (6) .

As a result, (7) overpaid for (8) . (9)

 

  1. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  2. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  3. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  4. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  5. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  6. (Month/Year)

     

  7. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  8. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) and (Month/Year)

    Choice 3 - (Month/Year) through (Month/Year)

     

  9. Choice 1 - You were eligible for SSI again on (Month/Day/Year), the day you filed for this money.

    Choice 2 - She was eligible for SSI again on (Month/Day/Year), the day she filed for this money.

    Choice 3 - He was eligible for SSI again on (Month/Day/Year), the day he filed for this money.

    Choice 4 - Null

     

2932. Situation Where Used:

Recipient's disability or blindness ceased.

(1) could not get SSI after (2) . (3) eligibility for payment based on (4) ended on (5) .

As a result, (6) overpaid for (7) .

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  2. (Month/Year)

     

  3. Choice 1 - Your

    Choice 2 - Her

    Choice 3 - His

     

  4. Choice 1 - disability

    Choice 2 - blindness

     

  5. (Month/Year)

     

  6. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  7. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) and (Month/Year)

    Choice 3 - (Month/Year) through (Month/Year)

     

2933. Situation Where Used:

Reversal of a disability decision or a blindness decision retroactive to initial eligibility.

(1) could not get SSI because (2) not (3) .

As a result, (4) overpaid for (5) .

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  2. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  3. Choice 1 - disabled

    Choice 2 - blind

  4. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  5. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) and (Month/Year)

    Choice 3 - (Month/Year) through (Month/Year)

     

2935. Situation Where Used:

Recipient is in noncompliance with treatment requirement for drug addiction and alcoholism.

(1) disability is based in part on (2) . (3) must accept treatment for this problem. Since (4) refused treatment, (5) could not get SSI starting with (6) .

As a result, (7) overpaid for (8) . (9)

 

  1. Choice 1 - Your

    Choice 2 - Her

    Choice 3 - His

     

  2. Choice 1 - drug addiction

    Choice 2 - alcoholism

    Choice 3 - drug addiction and alcoholism

     

  3. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  4. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  5. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  6. (Month/Year)

     

  7. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  8. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) and (Month/Year)

    Choice 3 - (Month/Year) through (Month/Year)

     

  9. Choice 1 - You were eligible for SSI again on (Month/Day/Year), the day you started treatment.

    Choice 2 - She was eligible for SSI again on (Month/Day/Year), the day she started treatment.

    Choice 3 - He was eligible for SSI again on (Month/Day/Year), the day he started treatment.

    Choice 4 - Null

2936. Situation Where Used:

Recipient was not a citizen or legal alien.

(1) could not get SSI because:

(2) not a citizen of the U.S.,

OR

•If (3) from a foreign country, the U.S. Immigration and Naturalization Service (INS) did not plan to let (4) stay in the U.S.

As a result, (5) overpaid for (6) . (7)

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  2. Choice 1 - You were

    Choice 2 - She was

    Choice 3 - He was

     

  3. Choice 1 - you are

    Choice 2 - she is

    Choice 3 - he is

     

  4. Choice 1 - you

    Choice 2 - her

    Choice 3 - him

     

  5. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  6. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) and (Month/Year)

    Choice 3 - (Month/Year) through (Month/Year)

     

  7. Choice 1 - You were eligible for SSI on (Month/Day/Year), the day you became a citizen, or INS decided to let you stay in the U.S.

    Choice 2 - She was eligible for SSI on (Month/Day/Year), the day she became a citizen or INS decided to let her stay in the U.S.

    Choice 3 - He was eligible for SSI on (Month/Day/Year), the day he became a citizen or INS decided to let him stay in the U.S.

    Choice 4 - Null

     

2937. Situation Where Used:

Recipient requests termination of eligibility effective for a month for which he received payment and such payment was not returned.

(1) asked us to stop sending SSI checks (2) . (3) agreed to return any check (4) received after (5) .

that month, (7) overpaid for (8) .

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  2. Choice 1 - to you

    Choice 2 - to her

    Choice 3 - to him

    Choice 4 - for her

    Choice 5 - for him

     

  3. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  4. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  5. (Month/Year)

     

  6. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  7. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  8. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) and (Month/Year)

    Choice 3 - (Month/Year) through (Month/Year)

     

2938. Situation Where Used:

Recipient is in a medical facility where Medicaid pays for more than half the cost of the care.

NOTE: OBSOLETE—(Replaced by 2939, May 31, 1988.)

(1) could not get more than $25 SSI money because all of the facts below were true.

(2) in a medical care facility, like a hospital or nursing home.

AND

(3) lived there for the full month.

AND

•Medicaid paid for more than half the cost of (4) care.

Also, if there was income on (5) record other than SSI, (6) might get less than $25 SSI money.

As a result, (7) overpaid for (8) (9)

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  2. Choice 1 - You were

    Choice 3 - She was

    Choice 4 - He was

     

  3. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  4. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  5. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  6. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  7. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  8. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) through (Month/Year)

     

  9. Choice 1 - ,

    Choice 2 - and

    Choice 3 - .

     

2939. (1) could not get more than (2) because all of the facts below were true.

(3) in a medical care facility, like a hospital or a nursing home.

(4) lived there for the full month.

•Medicaid paid for more than half the cost of (5) care.

Also, if there was income on (6) record other than SSI, (7) might get less than (8) . As a result, (9) overpaid for (10) (11)

 

  1. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

  2. Choice 1 - $25 in SSI money

    Choice 2 - $25 in SSI money for months before July 1988 or more than $30 SSI money for months July 1988 on

    Choice 3 - $30 in SSI money

     

  3. Choice 1 - You were

    Choice 2 - She was

    Choice 3 - He was

     

  4. Choice 1 - You

    Choice 2 - She

    Choice 3 - He

     

  5. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  6. Choice 1 - your

    Choice 2 - her

    Choice 3 - his

     

  7. Choice 1 - you

    Choice 2 - she

    Choice 3 - he

     

  8. Choice 1 - $25 in SSI money

    Choice 2 - $25 in SSI money for months before July 1988 or less than $30 SSI money for months July 1988 on

    Choice 3 - $30 in SSI money

     

  9. Choice 1 - you were

    Choice 2 - she was

    Choice 3 - he was

     

  10. Choice 1 - (Month/Year)

    Choice 2 - (Month/Year) through (Month/Year)

     

  11. Choice 1 -,

    Choice 2 - and

    Choice 3 - .

2940. PAYMENT STUB

Please Cut Along The Dotted Line

  • Please cut along the dotted line. Return the bottom portion of the stub with your payment.

  • Please use the enclosed envelope to mail your payment to us.

  • Be sure to tell us if you've changed your address.

  • Do not send cash or stamps.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

(1) •Make your check or money order payable to:
Administration  
  
Please show any change of address below•Print this on your check or money order: (3)

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  1. (Name of Recipient)

     

  2. $$$.¢¢

     

  3. Social Security Number and type of SSI Record


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900804260
NL 00804.260 - Automated Overpayment Notice (AONS) - 05/24/2002
Batch run: 01/27/2009
Rev:05/24/2002