BASIC (04-14)

NL 03001.015 Notice When Beneficiary or Recipient Has a Repay Agreement and is No Longer Entitled to Title II and Title XVI Monthly Benefits

A. When to use notice

Use this notice to when the beneficiary or recipient is no longer entitled to monthly benefits and he or she is now personally liable for the repayment of the debt. The notice is available in the Document Processing System.

B. Beneficiary or recipient has repay agreement and is no longer entitled to Title II or Title XVI monthly benefits notice

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 the money because you cashed those checks. You asked us to hold back [5] from your [6] payment each month until the [7] is paid back.

Since you are no longer entitled to monthly [8] benefits, you are personally liable for repayment of the [9]. If you cannot refund the full amount now, you should submit a partial payment. With this payment, send an explanation of your circumstances and a definite plan for paying the balance.

Your plan should show the amount you would pay each month and the date on which you will make each payment. You should make the initial payment within 30 days from the receipt of this letter. Please make your check or money order payable to "Social Security Administration, Claim No. [10]. We have enclosed an envelope for your convenience.

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-
Choice 2 -

Social Security
Supplemental Security Income (SSI)

[7]

Choice 1 -

total dollar amount of incorrect payment(s)

[8]

Choice 1-
Choice 2 -

Social Security
Supplemental Security Income (SSI)

[9]

Choice 1 -

dollar amount of remaining balance owed

[10]

Choice 1 -

beneficiary's claim number

[11]

Choice 1 -

field office telephone number

[12]

Choice 1 -

field office street address, city, state, zip code

C. Completed notice SSA sends when beneficiary or r