We are writing to you about court order number (1) . We stopped taking money out of (2) Social Security payments because (3) . The $ (4) that we sent you in (5) was the last payment due.

How to Pay Us Back

(6) should not have received the (7) that we sent after that date. Please return the (8) to us by check or money order. Make it payable to the Social Security Administration. Be sure to put (9) claim number on the check or money order.

IMPORTANT: Please use the Refund Envelope enclosed in our letter to mail your payment to us. Always include the claim number on the check or money order. If you no longer have the envelope, please mail your payment to:

Enclosure: Refund Envelope

Optional - Use the following only when he or she is not currently receiving Social Security payments

If          Receives Social Security Payments

If (10) receiving payments again, we will need a new court order before we can start withholding money for child support, alimony, or court ordered victim restitution.

Suspect Social Security Fraud?

Please visit http://oig.ssa.gov/r or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Questions

CTDO – Domestic
3901D - Foreign

1. 1. 

   Choice 1 - case

   Choice 2 - civil action number

2. 2. 

   full name as it appears on the order, possessive

3. 3. 

   Choice 1 - he is no longer receiving payments

   Choice 2 - she is no longer receiving payments

   Choice 3 - you ordered that we no longer withhold this money

   Choice 4 - he has paid more than the court order required

   Choice 5 - she has paid more than the court order required

4. 4. 

   dollar amount of last payment

5. 5. 

   month and year

6. 6. 

   Choice 1 - “You”

   (NOTE: Use this fill-in when sending this notice directly to the receiver. The receiver could be the court or another party.)

   Choice 2 - Name of receiver of garnished payments if other than the court
   (Use Name of receiver of garnished payments if other than the court, when sending this notice to the court asking them to return money they ordered us to send the receiver.)

7. 7. 

   combined dollar amount of all the checks that we shouldn't have sent

8. 8. 

   combined dollar amount of all the checks that we shouldn't have sent

9. 9. 

   Beneficiary’s name, possessive

   Optional

10. 10. 

    Choice 1 - you start

    Choice 2 - Beneficiary’s name starts