BASIC (04-14)

NL 03001.020 Follow-up Notice When Beneficiary or Recipient is No Longer Entitled to Title II and Title XVI Benefits and Has an Agreement to Repay

A. When to use notice

Use this notice to follow up when the beneficiary or recipient has an agreement to repay and is no longer entitled to monthly benefits. The notice is available in the Document Processing System.

B. Follow up notice when the beneficiary or recipient is no longer entitled to Title II and Title XVI benefits and has an agreement to repay for

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.

What You Should Do

Since you are no longer entitled to monthly [8] benefits, you are personally liable for repayment of the [9]. We have written to you about this before, but you have not settled this matter. You should repay this money now, or contact us about how you will pay us back.

If We Do Not Hear From You

If you do not pay us or get in touch with us about this matter 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-
Choice 2 -

Social Security
Supplemental Security Income (SSI)

[7]

Choice 1-
Choice 2 -

Social Security
Supplemental Security Income (SSI)

[8]

Choice 1-

total dollar amount of incorrect payment(s)

[9]

Choice 1 -

dollar amount of remaining balance owed

[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 follow up notice when the beneficiary or recipient is no longer entitled to Title II o