TN 96 (05-23)

NL 00703.200 Request for Payment of Misused Funds

(GN 00604.045)

Document Identifier for Word Processor: E3200

DPS

EXHIBIT LETTER

We are writing to let you know that you will have to return $ (1) of the (2) money we sent you as (3) payee. We have decided that you did not use this money for (4) as you agreed to do. For that reason, you must pay us back. The following gives you more information about our decision.

How Do We Reach Our Decision

(5)

 

How To Pay Us Back

There are two ways you can pay us back.

• •

  You can send us a check or money order for the full amount you owe us. Make your check or money order out to the Social Security Administration. Be sure to put (6) (7) on it. Please use the enclosed envelope to mail your check or money order to us.

• •

  If you can not send the full amount now, send as much as you can. Then contact any Social Security office. You can pay the rest of the money you owe by making monthly payments.

3100FC - Foreign

We will make sure (8) gets the money you return.

 

If You Have Any Questions

3901 - Domestic

3901D - Foreign

 

Enclosure:

Refund Envelope

Fill-ins:

1. (1) 

   amount of misused funds to be refunded, in the format 365.00

2. (2) 

   Social Security, Supplement Security Income, Social Security and Supplement Security Income, Black Lung

3. (3) 

   beneficiary or recipient's full name, possessive case, in the format of “John Day's”

4. (4) 

   them

5. (5) 

   narrative discussion of the misuse decision

6. (6) 

   “Social Security number” (Title XVI cases), “claim number” (Title II cases), or “Black Lung claim number” as appropriate.

7. (7) 

   Actual claim or Social Security number, in the format, XXX-XX-XXXX AI or
   
   XXX-XX-XXXX A.

8. (8) 

   first name of the beneficiary or recipient, if child; if adult, “Mr.” or “Ms.” last name

See NL 00703.100 for 3100FC text. See NL 00703.005E. for 3901D and 3901C text and fill-in.