DBC035 (Optional if the beneficiary has a representative payee)

The information given in this notice concerns _1_.

You were recently notified that the last disability payment you are entitled to is for the month of _2_.

Since you are no longer entitled to disability benefits, your hospital and medical insurance coverage under Medicare ends the last of _3_.

Overpayment Information

Our records show you received $_4_ more in Social Security benefits than you should have. This happened because you were paid benefits for _5_ months after _6_. The above amount includes medical insurance premiums of $_7_ which were withheld from your benefit check(s) for the same period.

How To Pay Us Back

You should refund the amount shown above within 30 days from the day you get this letter. In addition, you should also include $_8_ to pay your medical insurance premiums due for _9_. Please make your check or money order payable to “Social Security Administration, Claim No. _10_,” and send it to us in the enclosed envelope.

If You Disagree With This Decision

If you request a waiver or reconsideration within 30 days of the date of this notice, you will not have to repay _11_ overpayment until a review of _12_ case is completed. The review is described in more detail on the attached Form SSA-3105, Important Information About Your Appeal and Waiver Rights.

Please call, write, or visit any Social Security office if you want to request reconsideration or if you believe you should not have to repay the overpayment and want to request a waiver. The people there will be glad to help you complete the forms for reconsideration (SSA-561-U2, Request for Reconsideration) and/or waiver (SSA-632-BK, Request for Waiver of Overpayment Recovery or Change in Repayment Rate).

If You Again Become Disabled

If your condition again prevents you from doing substantial gainful work before age 65, you should get in touch with any Social Security office about filing a new application for disability benefits. If you apply promptly and are again found entitled to disability benefits, your benefit payments may start with the first full month in which you were again disabled.

If You Are Now age 62 or Over

Retirement benefits are payable at a reduced rate as early as age 62. If _13_ _14_ age 62 or over, you may wish to ask the people in any Social Security office for more details.

INFC08 (Optional if SNO002 is requested)

Things To Remember

SNO002 (Optional for SNO beneficiary)

We are sending you this letter in both a standard print version and _15_. You will receive them in separate envelopes.

If You Have Any Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at _16_. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

_17_

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.

Enclosures:

SSA-3105

Refund Envelope

Fill-ins:

1. 1. 

   (DBC035 if required) Beneficiary’s name

2. 2. 

   MM/YYYY last month benefits are due

3. 3. 

   MM/YYYY last month when the beneficiary is entitled to Medicare

4. 4. 

   Amount of overpayment

5. 5. 

   Number of months the beneficiary is overpaid

6. 6. 

   MM/YYYY last month benefits are due

7. 7. 

   Amount of Medicare insurance premiums included in the overpayment

8. 8. 

   Amount of Medicare insurance premiums

9. 9. 

   MM/YYYY last month that Medicare insurance premiums are due

10. 10. 

    Claim Number including BIC

11. 11. 

    Beneficiary’s full name/your

12. 12. 

    Beneficiary’s full name/your

13. 13. 

    you/the children/Beneficiary’s full name

14. 14. 

    are/is

15. 15. 

    (SNO002 if required) in a Braille version/on a compact disc in Microsoft Word format/on an audio compact disc/a large print version

16. 16. 

    FO phone number

17. 17. 

    FO street address, city, State, and ZIP code

The Processing Center (PC) will send this notice when Terminating, Attainments, Transfers, and Terminations (TATTER) notices are generated that require the technicians to review for an overpayment due to disability cessation. During the review, the PC technicians will also determine whether the notice contains the special notice option (SNO) indicator.

• •

  Use DBC035 if the beneficiary has a rep payee.

• •

  Use INFC08 and SNO002 if the beneficiary has requested SNO options 3, 4, 6, or 7.