BASIC (04-14)

NL 03001.010 Failure to Make a Monthly Payment Follow Up Notice for Title II and Title XVI

A. When to use notice

Use this notice to when beneficiary or recipient fails to make the monthly payment based on a signed repay agreement. The beneficiary or recipient will have a specific amount of time to adhere to the agreement before the Agency send the case to the Office of the Inspector General or the United States Secret Service for prosecution. The notice is available in the Document Processing System.

B. Failure to make monthly payment follow-up notice for Title II and Title XVI

We are writing to you about your agreement to repay us [1] for [2] [3] checks you cashed after [4] death.

Your Agreement

You agreed to repay [5] each month until the total amount of [6] is paid back.

What Our Records Show

We have not received the [7] payment that was due by [8]. If you cannot send us the payment by [9], please get in touch with us. If you have already sent this payment, please disregard this request.

If We Do Not Hear From You

If you do not pay us or get in touch with us about this by [10], we will consider sending this case to the Office of the Inspector General or the United States Secret Service for 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 [11]. 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: [12]

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 -

total dollar amount of incorrect payment(s)

[2]

Choice 1-

name of beneficiary (possessive)

[3]

Choice 1-
Choice 2 -

Social Security
Supplemental Security Income (SSI)

[4]

Choice 1-
Choice 2 -

his
her

[5]

Choice 1 -

dollar amount of monthly payment

[6]

Choice 1 -

total dollar amount of incorrect payment(s)

[7]

Choice 1 -

dollar amount of monthly payment

[8]

Choice 1 -

month/day/year in the format (example) December 31, 2000

[9]

Choice 1 -

month/day/year in the format (example) December 31, 2000

[10]

Choice 1 -

month/day/year in the format (example) December 31, 2000

[11]

Choice 1 -

field office telephone number

[12]

Choice 1 -

field office street address, city, state, zip code

C. Completed failure to make monthly payment follow-up notice for Title II and Title XVI

Social Security Administration
Retirement, Survivors and Disability Insurance
Important Information

100 East Capitol St. SE
Washington, DC 20019

Phone: (202) 555-5555

Office Hours: 8:30 a.m. until 5:00 p.m.

Date:

Claim Number: 123-00-6789A