We are writing to let you know that you will have to return $ (1) of the (2) money we sent you as representative payee for the individual(s) shown on the enclosed list. We determined that you did not use this money as you agreed. For that reason, you must pay us back. The following gives you more information about our determination.

Optional – use if previously advised of misused funds

You were previously advised that you owed $(3) because you did not use the money for the individuals shown on the attached list as you agreed. Because you failed to return this money, we are allowed to collect this money from you.

How We Reached Our Decision

(4)

How To Pay Us Back

Send us a check or money order for the full amount you owe us. Make your check or money order payable to the Social Security Administration and attach a copy of the enclosed list of the affected beneficiaries. Always include your claim number (as shown above) on your check or money order. Be sure to return both the check and a copy of the list of individuals in the enclosed envelope.

If you do not pay us back, the law allows us to use our debt collection tools, such as benefit adjustment, wage garnishment, and credit bureau reporting to collect the misused amount from you.

If You Disagree With The Decision

Please tell us within 10 days of the date of this letter if you disagree with the determination that you did not use the money as you agreed. You will also need to give us any proof showing that the benefits were used properly. We will review the evidence to see if you are right. We will notify you of our decision.

If we do not hear from you within 10 days and have not received the refund, we will contact you about our plans to recover the funds.

See Next Page

If You Have Any Questions

If you have any questions, you may call us toll-free at 1-800-772-1213 or call your local Social Security Office at (5). We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

(6)

 If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

Enclosure:

List of Beneficiary(s)

Refund Envelope

Send this notice when an organizational payee or an individual payee has misused benefits and we are requesting repayment of the funds.

Show the organization’s EIN as the claim number when the former rep payee is an organization. Show the payee’s SSN when the former rep payee is an individual.

Include the SSN of each affected beneficiary next to their names on the enclosed list.

Fill-ins:

1. (1) 

   Total amount of misused funds (Show the format as $$$.00)

2. (2) 

   Social Security, Special Veterans Benefits, Supplemental Security Income, Social Security and Special Veterans Benefits, Social Security and Supplemental Security Income

3. (3) 

   Total amount of misused funds

4. (4) 

   Narrative discussion of the misuse decision

5. (5) 

   Phone number of local Social Security office

6. (6) 

   Address of local Social Security office