Effective Dates: 6/20/2024 - Present

Identification Number:
NL 00720 TN 36
Intended Audience:See Transmittal Sheet
Originating Office:Systems
Title:Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program
Type:POMS Full Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM

Part NL – Notices, Letters and Paragraphs

Chapter 007 – Letters and Paragraphs for Title II, Title XVI, and Title XVIII

Subchapter 20 – Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program

Transmittal No. 36, 06/20/2024

Audience

PSC: BA, CA, CCRE, CS, DE, DS, ICDS, IES, ILPDS, IPDS, ISRA, NPR, PETE, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, BIES, BTE, CC, CCRE, CDT, CR, CTE, EIE, FDE, PETL, RECONE, RECONR, RECOVR;
OCO-ODO: BET, BTE, CCE, CST, CT, CTE, CTE TE, DE, DEC, DS, DSE, PAS, PCS, PETE, PETL, RCOVTA, RECONE, RECOVR;
FO/TSC: CS, CS TII, CSR, FR, OA, OS, RR, TA;

Originating Component

OEIS

Effective Date

Upon Receipt

Background

We are updating Program Operations Manual System (POMS) sections in NL 00720 effective with Manual Adjustment Credit and Awards Process (MADCAP) Beneficiary Notice Print Program's April 12, 2024 release.

The updates for notice language in this transmittal are a direct result of updates requested by the Office of Income Security Programs (OISP) via the clearance package process in support of the default to 10% overpayment withholding initiative.

Summary of Changes

NL 00720.004 Notice Groups for MADCAP

We updated exhibit notices E31 and E34 to include additional fill-ins needed to complete the notice of overpayment.

NL 00720.245 OPT Overpayment

We updated the language and fill-ins in the overpayment Universal Text Identifiers (UTI) OPT107, OPT159, OPT162, OPT163, OPT164, OPT170, and OPT180 to include information on 10% of their benefits being withheld to recover an overpayment.

NL 00720.295 RFU Refund

We updated the language and fill-ins in the refund UTIs RFU003 and RFU012 to include information on 10% of their benefits being withheld to recover an overpayment.

NL 00720.004 Notice Groups for MADCAP

A. Description of MADCAP Notice System

The MADCAP notice system produces a notice based on the action input through the operating system. Some notices can be totally automated without any requested paragraphs, but most require input of paragraph numbers and fill-in information.

The MADCAP system is programmed to generate all notice language and captions in a pre-established order, regardless of the order in which technicians input requested paragraphs.

B. Kinds of MADCAP Notices

There are three groups of MADCAP notices.

1. Group I

Group I notices are adjustment notices that cannot have requested paragraphs:

  • •

    SSA-L226 (Notice to Former Payee), and

  • •

    Payment Cycle Change notice.

2. Group II

Group II notices are adjustment notices that may have requested paragraphs:

  • •

    Category A, Adjustment Notices A20, A21, A22,

  • •

    Category B, Reinstatement Notice,

  • •

    Category C, Termination Notice,

  • •

    Category D, Suspension Notice, and

  • •

    Category O, Overpayment Notices E31, E32, and E34.

3. Group III

Group III notices are award notices, including change of payee awards, and the category E and M adjustment notices that may have requested paragraphs:

  • •

    Award Notice, including Change of Payee and Dual Entitlement (Primary after Auxiliary/Survivor),

  • •

    Dual Entitlement Award (Auxiliary/Survivor after Primary),

  • •

    HIMEX Award (Medicare only),

  • •

    Category M, Lump-Sum Death Payment, and

  • •

    Category E, (A18) One-Check-Only Notice.

C. Description of Group I Notices

Group I notices are completely automated notices, which the system generates based on the result of a technician's action. The technician does not determine what notice will generate, and cannot add any paragraphs.

D. Description of Group II Notices

1. How Group ll notices are produced

  1. a. 

    Group II notices will generate:

    • •

      automatically by the system; i.e., the technician does not have to indicate the notice code, or

    • •

      requested by the technician; i.e., A21, and all Category O notices must be indicated;

  2. b. 

    The technician must request at least one paragraph to explain the action taken in order to make the system produce a complete notice; and

  3. c. 

    If the action is solely a Medicare action, the technician does not have to request a paragraph to get a complete notice.

2. Automatically generated paragraphs

Most paragraphs that are automatically generated should not be keyed on the ENB. There are some that are both generated and requested.

Requesting a paragraph on the ENB will override their automatic generation criteria. Fill-ins may be required on the ENB for these certain paragraphs.

E. Description of categories under Group II

The following are categories under Group II:

1. Category A-A20

  1. a. 

    Category A-A20 explains:

    • •

      increase or decrease in monthly benefits,

    • •

      manual AERO actions,

    • •

      delayed retirement credits,

    • •

      adjustment of reduction factor, and

    • •

      other actions (see paragraphs ADJ027 , ADJ038, ADJ039 , RIN048, ADJ041 , ADJ043, ADJ044 , ADJ045, ADJ050 , ADJ051, ADJ052 and ADJ053)

  2. b. 

    Generation criteria are as follows:

    • •

      The new LAF status is C or D and

    • •

      The prior LAF status is C or D.

The A20 is not longer allowed on the ENB. The technician must provide the paragraphs they want to appear in the A20 notice. Failure to provide the necessary Paragraphs and Fill-ins causes the system to produce the A-20 notice with a completion code of 'S'. A manual action by the technician to complete the notice will be required.

Example: C*ADJ027 ,A,08/2011,C.

2. Category A-A21

Category A-A21 explains the withholding of an overpayment after the initial notification of the overpayment has been sent. Generation criteria are as follows:

  • •

    The special A21 notice code is indicated; and

  • •

    The new LAF status is C or D;

  • •

    The prior LAF status is C or D.

The technician must provide the overpayment amount to be recovered with the A21 notice code, to use as a Fill-in in paragraph OPT159 . Failure to provide the overpayment amount will result in the A21 notice being produced with a completion of 'S' for manual completion by the technician.

Example: C*A21,600.00.

3. Category A-A22

Category A-A22 explains actions taken on:

  • •

    work notices,

  • •

    readjustment rate cases, and

  • •

    all other miscellaneous adjustment actions not covered in the A20 or A21 notices.

Generation criteria are as follows:

  • •

    The new LAF status is C or D, and

  • •

    The prior LAF status is C or D.

NOTE: 

Do not enter the special A22 notice code on the ENB. The system automatically generates the A22 notice, if the above generation criteria are met and no other notice code is indicated on the ENB,. the system automatically generates the A22 notice.

Example: C*.

4. Category B

Category B is used when reinstating benefits. Generation criteria are as follows:

  • •

    The new LAF is C or D, and

  • •

    The old LAF is S or T or U or X.

The reinstatement/resumption date must be provided as the first entry on the ENB, for use as a Fill-in in paragraph RNS031 . Failure to provide the reinstatement/resumption date will result in the reinstatement/resumption notice being produced with a completion of 'S' for manual completion by the technician.

Example: C*08/1992.

5. Category C

Category C notifies beneficiaries that benefits have been terminated. Generation criteria are as follows:

  • •

    The new LAF is T (excluding T1) or U or X (excluding X1), and

  • •

    The old LAF is C or D or S or T or U or X.

6. Category D

Category D is used when benefits are suspended. Generation criteria are as follows:

  • •

    The new LAF is S, and

  • •

    The old LAF is C or D or S or T or U or X.

7. Category 0-E31

Category 0-E31 is used when an initial overpayment is being established and recovery is proposed via benefit withholding. Generation criteria are as follows:

  • •

    Notice code E31 is indicated.

  • •

    The new LAF status is C or D, and

  • •

    OVERPAYMENT is initially being established, and

  • •

    No previous overpayment is present on the MBR in the O/U PAY or PAR REC fields.

    Example: C*E31,150.00,06/2024.

NOTE: 

The technician must provide a complete explanation of the overpayment. i.e. AAA031 , OPT122 , OPT132 , OPT181 , PAY184 or TBL019 . For more instructions on notifying overpaid beneficiaries, see GN 02201.009.

8. Category 0-E32

Category 0-E32 is used when an initial overpayment is established for a person in LAF S or LAF T and a refund is requested. Generation criteria are as follows:

  • •

    Notice code E32 is indicated,

  • •

    The LAF is S or T (excluding T1) or U or X (excluding X1), and

  • •

    OVERPAYMENT is initially being established, and

  • •

    No previous overpayment is present on the MBR in the O/U PAY or PAR REC fields.

NOTE: 

The technician must provide a complete explanation of the overpayment. i.e. AAA031 , OPT122 , OPT132 , OPT181 , PAY184 or TBL019 . For more instructions on notifying overpaid beneficiaries, see GN 02201.009.

9. Category 0-E34

Category 0-E34 is sent to a beneficiary on the same record as the overpaid beneficiary when the overpayment cannot be recovered from the benefits of the overpaid person. Generation criteria are as follows:

  • •

    Notice Code E34 is indicated,

  • •

    The LAF is C or D, and

  • •

    OVERPAYMENT is initially being established, and

  • •

    No previous overpayment is present on the MBR in the O/U PAY or PAR REC fields.

NOTE: 

The technician must provide a complete explanation of the overpayment. i.e. AAA031 , OPT122 , OPT132 , OPT181 , PAY184 or TBL019 .

For more instructions on notifying overpaid beneficiaries, see GN 02201.009

Also, the name of the overpaid beneficiary and the amount of the overpayment must be provided with the E34 notice code, for use as Fill-ins in paragraph OPT163 . Failure to provide the necessary Fill-ins will result in an ‘invalid entry’ edit on the MACADE screen, which requires Fill-ins in order to proceed to the next screen.

Example: C*E34,JOHN DOE,150.00,125.00,10/2024.

F. Description of Group III Notices

Under Group III:

  • •

    Award notices and Category M, Lump-Sum Death Payment notices are automatically generated, and

  • •

    Category E notices must be requested.

An award notice can have a combination of computer generated paragraphs and paragraphs requested by the CR, CA or BA.

G. Description of categories under Group III

The following are categories under Group III:

1. Award notices including change of payee or dual entitlement (primary after auxiliary or survivor)

A Notice of Award is automatically generated when:

  • •

    MADCAP processes an initial, conditional, or deferred award;

  • •

    The Special Indicator (SIC) is EC which represents entitlement conversion; or

  • •

    The Letter Identification (LID) entry is completed indicating a change of payee. (The third line heading is Important Information).

Generation criteria are as follows:

  • •

    The ABT is 1 or 5 or 6; or

  • •

    The LID is Y.

2. Dual entitlement (auxiliary or survivor after primary, checks combined)

Dual entitlement (auxiliary/survivor after primary, checks combined) is used when a beneficiary is in pay status and entitlement to auxiliary benefits on another account is initially being established via the beneficiary's primary record. Generation criteria are as follows:

  • •

    The LAF is C, S, D or E,

  • •

    D30 is coded as the first entry on the ENB,.

  • •

    When D30 is coded, paragraph BEN089 is required as the introductory paragraph and must be provided on the ENB along with the necessary fill-ins.

    EXAMPLE: C*D30*BEN089,A,999-99-9999,05/2011.

NOTE: 

Paragraph AWD017 is not systems derived on the D30. If required, the technician must request it on the input record.

3. Category M, Lump-Sum Death Payment (LSDP)

Category M, Lump-Sum Death Payment, is used when processing a lump-sum death payment only. This notice is automatically generated when the Payment Identification Code (PIC) column in RID 5 contains the claims symbol of G (any subscript).

4. Category E (A18) One-Check-Only Notice

Category E (A18) is a Group III notice and is used for ‘One Check only’ notices. This means use this UTI when a payment is in addition to regular payments. This notice is automatically generated when the A18 notice code is keyed as the first entry on the ENB. Please refer to the description of Category III notices before keying.

If A18 is used on an adjustment notice it will produce an “S” notice.

The Fill-ins for UTI's listed below are mutually exclusive paragraphs that must be provided with the A18 notice code. Failure to provide the necessary Fill-ins will result in the A18 notice being produced with a completion code of 'S' for manual completion by the technician.

Example: C*A18,B,JOHN DOE.

  • •

    ADJ058 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'A' or ' D' or 'E' or 'H' or 'I' or 'L'.

  • •

    ADJ059 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'C'.

  • •

    ADJ060 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'F'.

  • •

    ADJ061 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'G'.

  • •

    ADJ062 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'M'.

  • •

    ADJ063 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'J'.

  • •

    ADJ064 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'K'.

  • •

    ADJ048 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'B'. In this situation, a second Fill-in (fill-2) representing a person's name must be provided with A18.

  • •

    ADJ049 . This paragraph will automatically generate if the first Fill-in (fill-1) provided with A18 is 'N'.

NOTE: 

The second Fill-in only needs to be provided when the first Fill-in is 'B'. The system will automatically generate the proper UTI based on the value of Fill-in 1

Exclusions

  • •

    A18 cannot be used on BOND Notices

  • •

    A18 cannot be used on Adjustment notices (Group II Notices)

NL 00720.245 OPT Overpayment

OPT028 NEW OVERPAYMENT AMOUNT INCLUDES PRIOR OVERPAYMENT (M05)

(Requested)

Caption: Your Benefits

However, the total overpayment is  (1)  , which includes a prior overpayment of  (2)  .

Fill-in values:
Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
Total overpayment
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Current balance of prior overpayment

OPT107 OVERPAYMENT RECOVERED FROM ONE MONTH'S BENEFIT (A57)

(Requested/Systems Generated in E31 and E34)

Caption: Your Benefits

We will withhold 10 percent from (1)   (2)  payment to start recovering the money we  (3)   (4)  . This is the payment you would normally receive on or about  (5)  . The minimum we will withhold is $10. If the total benefit is less than $10, we will withhold the entire benefit.

Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: your
Choice 2: Beneficiary's name (possessive)
Fill-in (2) – Systems Generated As A Date in Format Shown Below
First month of payment deduction in Month CCYY format
Fill-in (3) – Systems Generated
Choice 1: overpaid
Choice 2: incorrectly paid
Fill-in (4) – Systems Generated
Choice 1: you (NOT USED BY MADCAP)
Choice 2: him (NOT USED BY MADCAP)
Choice 3: her (NOT USED BY MADCAP)
Choice 4: Beneficiary's name (not possessive)
Fill-in (5) – Systems Generated As A Date In Format Shown Below
Date of first payment being reduced for recovery in Month DD, CCYY format

OPT122 BENEFICIARY OVERPAID DUE TO SUSPENSION/TERMINATION (M13)

(Requested)

Caption: Your Benefits

Since we did not stop  (1)  payments until  (2)  ,  (3)  paid  (4)  too much in benefits.

Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: Beneficiary's Name (possessive)
Choice 2: your
Fill-in (2) – Systems Generated
MM/CCYY
Fill-in (3) – Systems Generated
Choice 1: he was
Choice 2: she was
Choice 3: you were
Fill-in (4) Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount of overpayment

OPT127 UNDERPAYMENT USED TO REDUCE/RECOVER AN OVERPAYMENT (M03)

(Requested)

Caption: Your Benefits

We used  (1)  of  (2)  benefits to recover  (3)  of an overpayment on this record.

Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Amount used for recovery
Fill-in (2) - Requested As A One Position Alpha Character or Language
Choice 1: (A) your
Choice 2: Name of Beneficiary
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) all
Choice 2: (B) part

OPT132 DIRECT DEPOSIT — JOINT ACCOUNT — RECOVERY OF PAYMENTS MADE AFTER DEATH (A16)

(Requested)

Caption: Your Benefits

We paid  (1)  more in benefits than we should have. We deposited (2)  benefits for  (3)  into a bank account which  (4)  also owned. We can't pay benefits for the month of death,  (5)  , or later. Because  (6)  a joint owner of the bank account,  (7)  overpaid  (8)  .

Fill-in values:
Fill-in (1) Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (2) Requested
Full name of the deceased beneficiary, possessive
Fill-in (3) Requested As A Date In Format Shown Below
Month(s) and year(s) of incorrect payment
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: Beneficiary's first name
Fill-in (5) Requested
Month(s) and year(s) of incorrect payment
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (6) Systems Generated
Choice 1: Beneficiary's name is
Choice 2: you are
Fill-in (7) Systems Generated
Choice 1: Beneficiary's name is
Choice 2: you are
Fill-in (8) Requested
Amount of overpayment

OPT148 CROSS PROGRAM RECOVERY - T16 UNDERPAYMENT USED TO RECOVER T2 OVERPAYMENT (B88)

(System Generated)

Caption: Your Benefits

We used (1)  of  (2)  SSI benefits to recover some or all of an overpayment on this record.

Fill-in values:
Fill-in (1)
Amount of SSI under payment
Fill-in (2)
Choice 1: Beneficiary's Name possessive
Choice 2: your

OPT149 CROSS PROGRAM RECOVERY - T16 UNDERPAYMENT NOT USED TO REDUCED/RECOVER A T2 OVERPAYMENT (B89)

(System Generated)

Caption: What We Will Pay

We did not use any of  (1)  SSI benefits to recover an overpayment on this record.

Fill-in values:
Fill-in (1)
Choice 1: Beneficiary's Name
Choice 2: your

OPT151 OVERPAYMENT LIABILITY INFORMATION TO A REPRESENTATIVE PAYEE FOR OVERPAID BENEFICIARY (A27)

(Requested)

Caption: Your Benefits

As representative payee, you are personally liable for repayment unless you used the overpaid funds for the benefit of  (1)  , and the overpayment was made through no fault of your own.

Fill-in values:
Fill-in (1) – Systems Generated
Name(s) of beneficiary (ies)

OPT152 REPAY BENEFITS WITHHELD - PROTEST OF OVERPAYMENT RECEIVED TIMELY (LAF D to C ) (A44)

(Requested)

Caption: Your Benefits

We are paying  (1)  again beginning  (2)  because  (3)  asked us to review our overpayment decision. If we later find that our decision was correct, or that we cannot waive the overpayment,  (4)  will have to pay back the  (5)  which  (6)  . Someone from the local Social Security office will contact  (7)  to discuss the overpayment.

Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) - Requested As A Date In Format Shown Below
Date payments resumed MM/CCYY
Fill-in (3) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) – Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (6) – Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes
Fill-in (7) – Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her

OPT153 OVERPAYMENT WITHHELD FROM BENEFITS IS REPAID — PROTEST RECEIVED TIMELY (A46)

(Requested)

Caption: Your Benefits

 (1)  asked us to review our overpayment decision. While we review  (2)  case, we are sending  (3)  the money we withheld from  (4)  checks.

If we later find that our decision was correct, or that we cannot waive the overpayment,  (5)  will have to pay back the  (6)  which  (7)  . Someone from the local Social Security office will contact  (8)  to discuss the overpayment.

Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: You
Choice 2: Beneficiary's Name
Fill-in (2) – Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) – Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (4) – Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment-
Fill-in (7) – Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes
Fill-in (8) – Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her

OPT154 OVERPAYMENT PROTESTED - BENEFITS RESUMED AND WITHHELD BENEFITS REPAID - FOREIGN CLAIMS (A47)

(Requested)

Caption: Your Benefits

We are paying  (1)  again beginning  (2)  because  (3)  asked us to review our overpayment decision. If we later find that our decision was correct, or that we cannot waive the overpayment,  (4)  will have to pay back the  (5)  which  (6)  .

Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2) – Requested As A Date In Format Shown Below
Date payments resumed MM/CCYY
Fill-in (3) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) – Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (6) – Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes

OPT155 OVERPAYMENT PROTESTED - BENEFITS RESUMED - MONEY WITHHELD NOT REPAID - FOREIGN CLAIMS (A48)

(Requested)

Caption: Your Benefits

We are paying  (1)  again beginning  (2)  because  (3)  asked us to review our overpayment decision. For now, we are still withholding the money which we already subtracted from  (4)  checks.

If we later find that our decision was correct, or that we cannot waive the overpayment,  (5)  will have to pay back the  (6)  which  (7)  .

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) – Requested As A Date In Format Shown Below
Date payments resumed MM/CCYY
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the remaining overpayment
Fill-in (7) Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes

OPT156 OVERPAYMENT PROTESTED AFTER RECOVERY COMPLETED/STOPPED - REPAY BENEFITS WITHHELD - FOREIGN CLAIMS (A49)

(Requested)

Caption: Your Benefits

 (1)  asked us to review our overpayment decision. While we review  (2)  case, we are sending  (3)  the money we withheld from  (4)  checks. If we later find that our decision was correct, or that we cannot waive the overpayment,  (5)  will have to pay back the  (6)  which  (7)  .

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's Name
Fill-in (2) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
Fill-in (7) Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes

OPT158 INTRODUCTORY STATEMENT FOR CAT A-A22 NOTICE WHEN OVERPAYMENT ESTABLISHED AND ALIEN TAXATION INVOLVED (ADMINISTRATIVE ADJUSTMENT) (F70)

(Requested)

Caption: None

We are writing to give  (1)  new information about the  (2)  benefits which  (3)  on this Social Security record. In the rest of this letter, we will tell  (4)  :

  • •

    How we paid  (5)   (6)  too much in benefits; and

  • •

    What to do if  (7)  we are wrong about the overpayment.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) Requested As A One Position Alpha Character
Choice 1: (A) disability
Choice 2: (B) retirement
Choice 3: (C) survivor
Choice 4: (D) auxiliary
Fill-in (3) Systems Generated
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
Fill-in (7) Systems Generated
Choice 1: you think
Choice 2: he thinks
Choice 3: she thinks

OPT159 A21 NOTICE OVERPAYMENT RECOVERY (G51)

(System Generated)

Caption: Your Benefits

As we told  (1)  in our previous letter, we are withholding 10 percent of  (2)  benefits to recover the overpayment of  (3)  .

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) Systems Generated
Amount of the overpayment

OPT161 INTRODUCTORY PARAGRAPH E31 AND E32 NOTICES (G70)

(System Generated)

Caption: None

We are writing to give  (1)  new information about the  (2)  benefits which  (3)  on this Social Security record. In the rest of this letter, we will tell  (4)  :

  • •

    How we paid  (5)   (6)  too much in benefits; and

  • •

    What to do if  (7)  we are wrong about the overpayment.

Fill-in values:
Fill-in (1)
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2)
Choice 1: disability
Choice 2: retirement
Choice 3: survivor
Fill-in (3)
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
Fill-in (4)
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5)
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6)
Amount of the overpayment
Fill-in (7)
Choice 1: you think
Choice 2: he thinks
Choice 3: she thinks

OPT162 E31 AND E34 NOTICES MBP GREATER THAN OVERPAYMENT (G71)

(System Generated)

Caption: Your Benefits

We plan to collect the overpayment from the check which  (1)  will receive around  (2)  . We will reduce  (3)  check to  (4)  . The amount we will withhold is 10 percent of the total monthly benefits or $10 (whichever is more). If the total benefit is less than $10, we will withhold the entire benefits. We will send  (5)   (6)  regular monthly benefit amount again beginning  (7)  .

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (2) Systems Generated
DPRD check date in Month DD, CCYY format
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) Requested By Technician As A Money Amount
Amount of the reduced check
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) Requested By Technician As A Date in Format Shown Below
Date of first payment after recovery ends in MM/CCYY

OPT163 E34 NOTICE INTRODUCTORY PARAGRAPH (G72)

(System Generated)

Caption: None

We are writing to give  (1)  new information about Social Security benefits on this record. We paid  (2)   (3)  too much in Social Security benefits. In the rest of this letter, we will tell you:

  • •

    How we paid too much in benefits, and

  • •

    What to do if you think we are wrong about the overpayment.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2) Requested By Technician As A Name
Beneficiary's name
Fill-in (3) Requested By Technician As A Money AMount
Amount of the Overpayment

OPT164 OVERPAYMENT RECOVERY PROPOSED AGAINST OTHER BENEFICIARY E34 NOTICE (G73)

(System Generated)

Caption: None

We cannot recover the overpayment from the person who was overpaid. For this reason, we will withhold 10 percent of the total monthly benefits of each the money from the checks of other persons who are paid on the same Social Security record. The minimum we will withhold from each person is $10, but if a person's total benefit is less than $10, we will withhold the entire benefit.

OPT165 CHECK PARAGRAPH FUTURE WITHHOLDING OF OVERPAYMENT (G91)

(System Generated)

Caption: Your Benefits

We will pay  (1)  a monthly check of  (2)  until we start to collect the overpayment.

Fill-in values:
Fill-in (1)
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (2)
PMA or CMA in $$$$$.¢¢ format

OPT166 PREVIOUS CHECK WAS INCORRECT AMOUNT (M02)

(Requested)

Caption: Your Benefits

The check  (1)  received for  (2)  in  (3)  should have been for  (4)  . Therefore we paid  (5)   (6)  more in benefits than  (7)  due.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) – Requested As A Money Amount In Format $$$$$.¢¢
Amount of check
Fill-in (3) Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (4) Requested As A Money Amount In Format $$$$$.¢¢
Amount that should have been paid
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (7) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was

OPT167 OVERPAYMENT RECOVERED (M06)

(Requested)

Caption: Your Benefits

We have recovered all of the money  (1)  owed because of an overpayment.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT168 OVERPAYMENT BALANCE (M08)

(Requested)

Caption: Your Benefits

The total amount of the overpayment is  (1)  .

Fill-in values:
Fill-in (1) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment

OPT169 INCORRECT BENEFIT CAUSED INCORRECT PAYMENT, OVERPAYMENT OR UNDERPAYMENT (M10)

(Requested)

Caption: Your Benefits

Since we paid  (1)   (2)  for  (3)  , we paid  (4)   (5)   (6)  than  (7)  due.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount paid
Fill-in (3) Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
Fill-in (6) - Requested As A One Position Alpha Character
Choice 1: (A) more
Choice 2: (B) less
Fill-in (7) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was

OPT170 BENEFITS DEFERRED TO RECOVER AN INCORRECT PAYMENT/OVERPAYMENT (M11)

(Requested)

Caption: Your Benefits

We are withholding 10 percent of  (1)  benefits for  (2)  and  (3)  of  (4)  benefits for  (5)  to recover the  (6)  that was not due

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (2) Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (3) Requested As A Money Amount In Format $$$$$.¢¢
Amount of final adjustment
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) Requested As A Date In Format Shown Below
MM/CCYY of final adjustment
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment or incorrect payment

OPT171 OTHER BENEFICIARY OVERPAID DUE TO WORK (M12)

(Requested)

Caption: Your Benefits

We paid  (1)   (2)  too much in benefits because of work and earnings in  (3)  .

Fill-in values:
Fill-in (1) - Requested As A Language
Name of overpaid beneficiary
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (3) - Requested As A Date In Format Shown Below
CCYY

OPT179 PAID VS. PAYABLE (M01)

(Requested)

Caption: Your Benefits

We paid  (1)   (2)  for  (3)  . Since we should have paid  (4)   (5)  for  (6)  , we paid  (7)   (8)   (9)  than  (10)  due.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (3) Requested As A Date in Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) Requested As A Money Amount In Format $$$$$.¢¢
Correct Amount
Fill-in (6) Requested As A Date in Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (7) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (8) Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (9) Systems Generated
Choice 1: more
Choice 2: less
Fill-in (10) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was

OPT180 FOREIGN REFUND REQUEST ADJUSTMENT PROPOSED OVERPAYMENT EXCEEDS MBP (F24)

(System Generated)

Caption: How To Pay Us Back

You should refund this overpayment within 30 days. Please make your check or money order payable to the “Social Security Administration” and send it to us in the enclosed envelope.

Always include  (1)  Social Security claim number on the check or money order.

Please send your check or money order in United States currency or in local currency equal to the United States dollars. When you pay us in local currency, we use the exchange rate in effect at the time we receive your payment. If this causes a difference between the amount you pay us and the amount you owe us, we will let you know. If you cannot mail your payment directly to us, please contact your Federal Benefits Unit for help in making the refund. Visit  (2)  for a list of Federal Benefits Units.

If we do not receive your refund within 30 days, we plan to recover the overpayment by withholding 10 percent of  (3)  total benefit or $10 (whichever is more) each month beginning with the benefit  (4)  will receive on or about  (5)  . We will continue to withhold from  (6)  benefit until the overpayment is fully recovered.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: your
Choice 2: Beneficiary Name possessive
Fill-in (2) Systems Generated
Choice 1: www.socialsecurity.gov/foreign/foreign.htm
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: Beneficiary Name possessive
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) Systems Generated
MM/DD/CCYY
Fill-in (6) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT181 (M07) DUPLICATE CHECK OVERPAYMENT

(Requested)

Caption: Your Benefits

We sent  (1)  two checks for  (2)  , both in the amount of  (3)  and both checks were cashed. Since  (4)  due only one check, we paid  (5)   (6)  too much in benefits.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2) Requested As A Date in Format Shown Below
MM/CCYY
Fill-in (3) Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (4) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment

OPT182 PRIOR OVERPAYMENT — WORK MONTHS PREVENTED RECOVERY (A29)

(Requested)

Caption: Your Benefits

Our records show that we paid  (1)   (2)  too much in  (3)  . In our previous letter, we told  (4)  that we would withhold benefits in  (5)  to recover  (6)  amount. But  (7)  recent report shows that  (8)  worked during  (9)  . Because of that work, no benefits were payable for that period. Since we could not use benefits for those months to recover the amount  (10)  owed,  (11)  us  (12)  .

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: Beneficiary's name
Choice 2: you
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
Fill-in (3) Requested As A Date in Format Shown Below
Year of prior overpayment in CCYY
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) Requested As A Date in Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (6) Requested As A One Position Alpha Character
Choice 1: (A) this
Choice 2: (B) part of this
Fill-in (7) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (9) Requested As A Date in Format Shown Below
Choice 1: month and year of work MM/CCYY
Choice 2: months and years of work MM/CCYY through MM/CCYY
Fill-in (10) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (11) Systems Generated
Choice 1: you still owe
Choice 2: he still owes
Choice 3: she still owes
Fill-in (12) Requested As A Money Amount In Format $$$$$.¢¢
Overpayment Amount

OPT262 OVERPAYMENT ESTABLISHED DUE TO INCORRECT COMPUTATION, A LEGALLY DEFINED OVERPAYMENT OR TO RECOVER A SKELETON DUE PROCESS OVERPAYMENT

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because the payment amount was incorrect. We corrected  (3)  record, which caused (4)  benefit amount to decrease.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT263 OVERPAYMENT ESTABLISHED DUE TO SUBVERSIVE ACTIVITY

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  convicted of a crime against the United States.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was

OPT264 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY DID NOT HAVE A CHILD IN THEIR CARE

(Requested)

Caption: Your Benefits

 (1)  received (2)  too much in benefits because  (3)  a child in  (4)  care who receives benefits from us.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you no longer have
Choice 2:he no longer has
Choice 3: she no longer has
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT265 OVERPAYMENT ESTABLISHED BECAUSE A WARRANT FOR THE BENEFICIARY'S ARREST EXISTS

(Requested)

Caption: Your Benefits

 (1)  received (2)  too much in benefits. We should not have paid  (3)  because of a warrant for  (4)  arrest.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2:him
Choice 3: her
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT266 OVERPAYMENT ESTABLISHED BECAUSE OF STATE OR FEDERAL ASSISTANCE

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because (3)  received State or Federal assistance.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT267 OVERPAYMENT CAUSED BY REPRESENTATIVE PAYEE MISUSE OF BENEFITS

(Requested)

Caption: Your Benefits

 (1)  received (2)  too much in benefits because  (3)  misused funds while acting as a representative payee.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT268 OVERPAYMENT CAUSED BY DISABILITY CESSATION

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we cannot pay benefits after  (3)  disability ends.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Requested As A One Position Alpha Character or Wage Earner's Name for Choice 4
Choice 1: (A) your
Choice 2: (B) his
Choice 3: (C) her
Choice 4: Wage Earner's name (possessive)

OPT269 OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF PROVISIONAL BENEFITS ON A CLAIM THAT WAS LATER DENIED

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  received temporary benefits while we were making a decision on  (4)  claim that we later denied.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT270 OVERPAYMENT ESTABLISHED DUE TO CROSS-BENEFIT ADJUSTMENT

(Requested)

Caption: Your Benefits

We moved  (1)  overpayment of  (2)  to  (3)  for collection.

Fill-in values:
Fill-in (1) Requested As A Alpha Character or the Beneficiary's Name
Choice 1: (A) another person's
Choice 2: Beneficiary's full name (possessive)
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: Beneficiary’s full name

OPT271 OVERPAYMENT ESTABLISHED DUE TO CHANGE IN THE AMOUNT OR COMMENCEMENT OF THE GOVERNMENT PENSION OFFSET

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we must offset  (3)  benefit payments due to  (4)  receipt of a government pension.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT272 OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF A PENSION BASED ON WORK NOT COVERED BY SOCIAL SECURITY TAXES

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because (3)  received a pension based on work not covered by Social Security taxes.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Requested As A One Position Alpha Character or Wage Earner's name for Choice 4
Choice 1: (A) you
Choice 2: (B) he
Choice 3: (C) she
Choice 4: Wage Earner's name (not possessive)

OPT273 OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF PAYMENTS AFTER CONFINEMENT TO A MENTAL INSTITUTION BECAUSE OF A COURT ORDER

(Requested)

Caption: Your Benefits

 (1)  received (2)  too much in benefits because  (3)  received payments after being confined to an institution because of a court order.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT274 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WAS AN ALIEN LIVING OUTSIDE THE UNITED STATES WHILE RECEIVING BENEFITS

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because (3)  not a United States citizen and  (4)  outside the country for six months in a row.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is
Fill-in (3) Systems Generated
Choice 1: you are
Choice 2: he was
Choice 3: she was

OPT275 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WORKED OUTSIDE THE US IN A JOB NOT COVERED UNDER SOCIAL SECURITY TAXES

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  worked outside the United States in a job not covered by United States Social Security taxes.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT276 OVERPAYMENT ESTABLISHED DUE TO PRISONER SUSPENSION

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of  (3)  criminal conviction and confinement in a correctional institution for more than 30 days.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT277 OVERPAYMENT ESTABLISHED DUE TO DEATH RECLAMATION, REPRESENTATIVE PAYEE ELECTRONIC FUNDS TRANSFER (EFT) AFTER DEATH OR REPRESENTATIVE PAYEE DEATH

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we cannot pay benefits for the month of death or later.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment

OPT278 OVERPAYMENT ESTABLISHED DUE TO PERMANENT DEDUCTIONS RESULTING FROM THE ANNUAL EARNINGS TEST

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of  (3)  work and earnings.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Choice 4: null

OPT279 OVERPAYMENT ESTABLISHED DUE TO DEATH SUPER-ENDORSEMENT

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  signed and cashed a check for the month of death or later.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT280 OVERPAYMENT ESTABLISHED DUE TO A CHANGE IN MARITAL STATUS

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of a change in  (3)  marital status.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT281 OVERPAYMENT ESTABLISHED DUE TO ENTITLEMENT TO WORKERS' COMPENSATION, PUBLIC DISABILITY OR BOTH

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of  (3)  receipt of workers’ compensation, public disability payments, or both of these payments.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT282 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY CONTINUED TO RECEIVE BENEFITS AFTER THE AGE OF 18

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we do not pay benefits once a student reaches age 18, unless he or she is a full-time elementary or high school student.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment

OPT283 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY CONTINUED TO RECEIVE BENEFITS AFTER AGE 19 OR 22

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we do not pay benefits once a full-time student reaches age 19 , unless  (3)  blind or disabled, or meet(s) an exception which allows benefits to continue:

  • •

    for 2 months after a student turns 19, or;

  • •

    until the end of the school term, whichever comes first.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you are
Choice 2: he is
Choice 3: she is

OPT284 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY IS NO LONGER IN FULL-TIME SCHOOL ATTENDANCE

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we do not pay benefits once a student stops going to school full-time.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment

OPT285 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY REFUSED TO ACCEPT VOCATIONAL REHABILITATION

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we should not have paid benefits when (3)  refused vocational rehabilitation services.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT286 OVERPAYMENT ESTABLISHED DUE TO UNPAID ATTORNEY FEES

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of unpaid attorney's fees.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment

OPT287 OVERPAYMENT ESTABLISHED RAILROAD RETIREMENT BOARD EARNINGS WERE INCORRECTLY USED TO ESTABLISH THE BENEFICARY'S ENTITLEMENT

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  received incorrect payments from the Railroad Retirement Board.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT288 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICARY WAS NOT A UNITED STATES (U.S.) CITIZEN OR LAWFULLY PRESENT IN THE U.S.

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  received payments even though  (4)  not a United States citizen or lawfully present in the U.S.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was

OPT289 OVERPAYMENT ESTABLISHED BECAUSE THE MONTH OF ENTITLEMENT WAS INCORRECT

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of a change in the month  (3)  benefits started.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT290 OVERPAYMENT ESTABLISHED DUE TO MULTIPLE ENTITLEMENTS

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  received payments on two or more records for the same month(s).

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT291 OVERPAYMENT ESTABLISHED BECAUSE INSURED STATUS WAS NOT MET

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  worked long enough under Social Security to receive monthly benefits.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you have not
Choice 2: he has not
Choice 3: she has not

OPT292 OVERPAYMENT ESTABLISHED BECAUSE THE BENFICIARY MISUSED FUNDS WHILE SERVING AS A REPRESENTATIVE PAYEE

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  misused benefits that  (4)  received as the representative payee for another person.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT293 OVERPAYMENT CAUSED BY SUBSTANTIAL GAINFUL WORK ACTIVITY (SGA) DURING THE EXTENDED PERIOD OF ELIGIBILITY (EPE) OR DISABILITY CESSATION DUE TO SGA

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of  (3)  work activity.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Requested As A One Position Alpha Character or the Wage Earner's Name for Choice 4
Choice 1: (A) your
Choice 2:(B) his
Choice 3:(C) her
Choice 4: Wage Earmer's name (possessive)

OPT294 OVERPAYMENT ESTABLISHED VIA CROSS PROGRAM RECOVERY (CPR) TO RECOVER A TITLE VIII SPECIAL VETERANS BENEFITS (SVB) PAID IN EXCESS

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in Special Veterans Benefit (SVB) payments.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment

OPT295 OVERPAYMENT CAUSED DUE TO INCORRECT PAYMENTS FOR MEDICARE SERVICES

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of incorrect payments for Medicare services.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment

OPT296 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFCIARY WAS CONVICTED OF A CRIME OR IMPRISONED FOR MORE THAN 30 DAYS DUE TO FELONIOUS HOMICIDE

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because of (3)  criminal conviction and imprisonment for more than 30 days.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

OPT297 OVERPAYMENT CAUSED BY WINDFALL OFFSET

(Requested)

Caption: Your Benefits

 (1)  received (2)  too much in benefits because  (3)  received Supplemental Security Income (SSI) payments  (4)   (5)  .

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) Systems Generated
Choice 1: from
Choice 2: in
Fill-in (5) Systems Generated
Choice 1: MM/CCYY through MM/CCYY
Choice 2: MM/CCYY

OPT298 OVERPAYMENT ESTABLISHED BECAUSE MORE THAN ONE PAYMENT WAS CASHED FOR THE SAME MONTH

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because we should not have paid two payments for the same month(s).

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment

OPT299 OVERPAYMENT ESTABLISHED DUE TO INVALID FAMILY RELATIONSHIPS

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  did not meet the relationship requirements to receive benefits.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT300 OVERPAYMENT ESTABLISHED BECAUSE OF INVALID ENTITLEMENT

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  did not qualify for benefits.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she

OPT301 OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WAS DEPORTED

(Requested)

Caption: Your Benefits

 (1)  received  (2)  too much in benefits because  (3)  deported from the United States.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's full name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the Overpayment
Fill-in (3) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was

NL 00720.295 RFU Refund

RFU001 REQUEST FOR REFUND - OVERPAID PERSON IN NONPAY STATUS NO CROSS PROGRAM ADJUSTMENT POSSIBLE (A19) (G13)

(Requested/Generated)

Caption: How To Pay Us Back

You should refund this overpayment of  (1)  within 30 days. Please make your check or money order payable to “Social Security Administration,” and send it to us in the enclosed envelope. Always include  (2)  Social Security claim number on your check or money order.

If you cannot refund the full  (3)  now, please send:

  • •

    A partial payment

  • •

    An explanation of why you cannot pay the full amount now, and

  • •

    A plan to repay the money

Fill-in values:
Fill-in (1) – Systems Generated (when it is not requested on the ENB) or Requested As A Money Amount in Format $$$$$.¢¢
Overpayment Amount
Fill-in (2) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) Systems Generated (when it is not requested on the ENB) Requested As A Money Amount in Format $$$$$.¢¢
Overpayment Amount

RFU003 REQUEST FOR REFUND AND ADJUSTMENT PROPOSED - OVERPAID PERSON IN NONPAY STATUS AND IS REPRESENTATIVE PAYEE FOR OTHER - OVERPAYMENT EXCEEDS MONTHLY PAYMENT (A26)

(Requested)

Caption: How To Pay Us Back

You should refund this overpayment of  (1)  within 30 days. Please make your check or money order payable to the “Social Security Administration,” and send it to us in the enclosed envelope.

Always include  (2)  Social Security claim number on your check or money order.

If we do not receive your refund within 30 days, we will withhold 10 percent of  (3)  total monthly benefit or $10 (whichever is more) starting with the payment you will receive  (4)  on or about  (5) . If the total benefit is less than $10, we will withhold the entire benefit. We will continue to withhold from  (6)  benefit until we recover the overpayment.

If you cannot refund the full overpayment now or cannot afford to have us withhold 10 percent of  (7)  full benefit, you may ask us to hold back a smaller amount each month. Contact us to discuss your plan for repaying the balance. You may need to show us proof of  (8)  assets, monthly income, and expenses. The minimum withholding amount we will accept is $10.

Fill-in values:
Fill-in (1) Systems Generated
Amount of Overpayment
Fill-in (2) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) Systems Generated
Choice 1: NULL
Choice 2: for him
Choice 3: for her
Fill-in (5) Systems Generated
Date of payment offset + one month in MM/DD/CCYY
Fill-in (6) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

RFU007 SSI OFFSET NOT APPLICABLE (A59)

(Requested)

Caption: Your Benefits

Our records show that  (1)  did not get SSI money for  (2)  . So we can refund all of the Social Security money we held.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY

RFU008 REFUND/RETURNED CHECK(S) USED TO REDUCE OVERPAYMENT (A34)

(Requested)

Caption: Your Benefits

We used the amount refunded to replace  (1)  the money we  (2)   (3)  .

Fill-in values:
Fill-in (1) Requested As A One Position Alpha Character
Choice 1: (A) some of
Choice 2: (B) null
Fill-in (2) Requested As A One Position Alpha Character
Choice 1: (A) incorrectly paid
Choice 2: (B) overpaid
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Choice 4: Beneficiary's Name

RFU012 REQUEST FOR REFUND AND ADJUSTMENT PROPOSED — OVERPAID PERSON IN CURRENT PAY — OVERPAYMENT EXCEEDS MONTHLY PAYMENT (A24)

(Requested/Generated)

Caption: How To Pay Us Back

You should refund this overpayment of $ (1)  within 30 days. Please make your check or money order payable to the “Social Security Administration,” and send it to us in the enclosed envelope.

Always include  (2)  Social Security claim number on your check or money order.

If we do not receive your refund within 30 days, we will withhold10 percent of  (3)  total monthly benefit or $10 (whichever is more) starting with the payment you will receive  (4)  on or about  (5) . We will continue withholding from  (6)  benefits until we recover the overpayment.

.

If you cannot refund the full overpayment now or cannot afford to have us withhold 10 percent of  (7)  benefit, you may ask us to hold back a smaller amount each month. Contact us to discuss your plan for repaying the balance. You may need to show us proof of  (8)  assets, monthly income, and expenses. The minimum withholding amount we will accept is $10.

Fill-in values:
Fill-in (1) - Systems Generated (when it is not requested on the ENB) Requested As A Money Amount in Format $$$$$.¢¢
Overpayment Amount
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: null
Choice 2: for him
Choice 3: for her
Fill-in (5) - Systems Generated (when it is not requested on the ENB) Requested As A Date In Format Shown Below
MM/DD/CCYY
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her

RFU020 FOREIGN REFUND REQUEST NONPAY STATUS (F19)

Caption: How To Pay Us Back

(System Generated)

You should refund this overpayment within 30 days. Please make your check or money order payable to “Social Security Administration,” and send it to us in the enclosed envelope. Always include  (1)  claim number on the check or money order. If you cannot refund the full  (2)  now, you should submit:

  1. a. 

    partial payment,

  2. b. 

    an explanation of your financial circumstances, and

  3. c. 

    a definite plan for repaying the balance.

If  (3)  pay us by check or money order, make sure that the check or money order is in United States (U.S.) dollars or in local currency equal to U.S. dollars. When (4)  pay us in local currency, we use the exchange rates in effect at the time we get  (5)  payment. If this causes a difference between the amount  (6)  pay us and the amount  (7)  us, we will let you know. If you cannot mail  (8)  payment to us, please contact your Federal Benefits Unit. Visit  (9)  for a list of FBUs. If you are in Canada, visit  (10)  to find the office that services your area. They will help you make the refund.

If you have questions about Medicare, please visit  (11)  for information.

Fill-in values:
Fill-in (1) Systems Generated
Choice 1: Beneficiary's name possessive
Choice 2: your
Fill-in (2) Systems Generated
Overpayment amount in $$$$$¢¢
Fill-in (3) Systems Generated
Choice 1: you pay
Choice 2: he pays
Choice 3: she pays
Fill-in (4) Systems Generated
Choice 1: you pay
Choice 2: he pays
Choice 3: she pays
Fill-in (5) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) Systems Generated
Choice 1: you pay
Choice 2: he pays
Choice 3: she pays
Fill-in (7) Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes
Fill-in (8) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (9) Systems Generated
www.socialsecurity.gov/foreign/foreign.htm
Fill-in (10) Systems Generated
www.ssa.gov/foreign/canada.htm
Fill-in (11) Systems Generated
Medicare.gov

NL 00720 TN 36 - Manual Adjustment, Credit and Award Process (MADCAP) Beneficiary Notice Print Program - 6/20/2024