BASIC (04-14)

NL 03001.001 Initial Request for Repayment of Incorrect Payment after Death Notice for Title II and Title XVI

A. When to use notice

Use this notice to notify the spouse or other endorser of the check that they have to repay money because of endorsing incorrect checks issued after the death of the beneficiary or recipient. This also includes seeking additional information from the estate of the deceased. The notice is available in the Document Processing System.

The processing center (PC) or field office (FO) technician who determines the incorrect payment after death is responsible for requesting this notice and providing the appropriate fill-ins.

B. Initial request for repayment of incorrect payment after death notice for Title II and Title XVI

We are writing to you about [1] [2] check(s) that [3] cashed after [4] death.

Our records show that [5] died on [6]. Since we were unable to stop [7] [8] until [9], payment(s) for [10] [11] made incorrectly. This money was not due [12] because no check is due [13] the month of death or later months. Treasury regulations require repayment of this amount.

The Department of Treasury can only recover the money for the check(s) dated [14] from the financial institution that cashed [15]. The financial institution may contact you about the check(s).

Enclosed [16] of the check(s) dated [17]. The person who endorsed the enclosed check(s) or cashed the check(s) owes the Social Security Administration [18]. If you endorsed the check(s) or cashed the check(s), you should repay the money. You can contact any Social Security office about how you will pay us back. If you did not endorse or cash the check(s) but have information about the person who did, please get in touch with us right away.

If you cash Social Security checks after the death of the beneficiary, the law allows us to refer cases to the Office of the Inspector General or the United States Secret Service for possible prosecution.

If You Have Any Questions

If you have any questions, you may call us at 1-800-772-1213, or call your local Social Security office at [19]. We can answer most questions over the phone. You may also write or visit any Social Security office. The office that serves your area is located at: [20]

If you do call or visit an office, please have this letter with you. It will help us answer your questions. If you plan to visit an office, you may want to call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

Fill-ins:

  

[1]

Choice 1 -

name of beneficiary (possessive)

[2]

Choice 1-
Choice 2 -

Social Security
Supplemental Security Income (SSI)

[3]

Choice 1-
Choice 2 -

was
were

[4]

Choice 1 -

name of beneficiary (possessive)

[5]

Choice 1 -
Choice 2 -

he
she

[6]

Choice 1 -

month/day/year in the format (example) March 12, 1999

[7]

Choice 1 -

name of beneficiary (possessive)

[8]

Choice 1 -
Choice 2 -

Social Security benefit payment(s)
Supplemental Security Income payment(s)

[9]

Choice 1 -

month/year in the format (example) June 2000

[10]

Choice 1 -

total dollar amount of incorrect payments

[11]

Choice 1 -
Choice 2 -

was
were

[12]

Choice 1 -

name of beneficiary

[13]

Choice 1 -
Choice 2 -

for
after

[14]

Choice 1 -
Choice 2 -

month/year
month/year through month/year in the format (example) July l999 through June 2000

[15]

Choice 1 -
Choice 2 -

it
them

[16]

Choice 1 -
Choice 2 -

is a photocopy
are photocopies

[17]

Choice 1 -
Choice 2 -

month/year in the format (example) April l999
month/year through month/year in the format (example) April l999 through June 1999

[18]

Choice 1 -

total dollar amount of incorrect payment(s)

[19]

Choice 1 -

field office telephone number

[20]

Choice 1 -

field office street address, city, state, zip code

C. Completed initial request for repayment of incorrect payment after death notice for Title II and XVI

Social Security Administration
Retirement, Survivors and Disability Insurance
Important Information

Miscellaneous Program Service Center
600 West Madison Street
Chicago, IL 60661-2474

Date:

Claim Number: 123-00-6789A

To the Estate of John Doe
103 Main Street
Washington, DC 20019

We are writing to you about John Doe's Social Security check(s) cashed after his death.

What Our Records Show

Our records show that John Doe died on March 12, 1999. Since we were unable to stop Mr. Doe's Social Security benefit payment(s) until June 2000, we incorrectly made payment(s) of $7,500. This money was not due Mr. Doe, because no check is due for the month of death or later months. Treasury regulations require that we collect any payments incorrectly paid.

The Department of Treasury can only recover the money for the check(s) dated July l999 through June 2000 from the financial institution that cashed them. The financial institution may contact you about the check(s).

Enclosed you will find photocopies of the check(s) dated April 1999 through June 1999. The person who endorsed the enclosed check(s) or cashed the check(s) owes us $1,500.

What You Need To Do

If you endorsed the check(s) or cashed the check(s), you should repay the money. You can contact any Social Security office about how you will pay us back. If you did not endorse or cash the check(s), but have information about the person who did, please get in touch with us right away.

The law allows us to refer cases to the Office of the Inspector General or the United States Secret Service for possible prosecution of Social Security checks cashed after the death of the beneficiary.

If You Have Any Questions

If you have any questions, you may call us at 1-800-772-1213, or call your local Social Security office at XXX-XXXX. We can answer most questions over the phone. You may also write or visit any Social Security office. The office that serves your area is:

611 E 6th
Baltimore, MD 21200

If you do call or visit an office, please have this letter with you. It will help us answer your questions. If you plan to visit an office, you may want to call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

Name

Assistant Regional Commissioner

Processing Center Operations

Enclosure(s):

Copy of Endorsed Check(s)


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0903001001
NL 03001.001 - Initial Request for Repayment of Incorrect Payment after Death Notice for Title II and Title XVI - 06/16/2014
Batch run: 06/16/2014
Rev:06/16/2014