Effective Dates: 11/01/2007 - Present Previous | Next

TN 3 (05-92)

NL 00803.110 Notice of Overpayment Forms

A. Introduction

Notice of Overpayment forms are the same for both manual and automated notices, except that AONS notices treat Form SSA-4017 (Payment Stub) as the last page of the AONS notice.

NOTE: AONS notices do not address penalty notification. However, do not suppress an AONS notice for this reason alone. If you decide to assess a penalty, send a separate penalty notice after release of the AONS notice.

B. Description

In addition to offering the repayment options in C. below, the Notice of Overpayment must give the following information:

  • •

    The cause of the overpayment;

  • •

    The amount of the overpayment and the months it occurred;

  • •

    A statement of the individual's right to appeal the overpayment determination; and

  • •

    The right to request relief from recovery (waiver) of the overpayment.

NOTE: The Notice of Overpayment also has an attachment page, A Detailed Explanation of Your Overpayment, which you must always complete following instructions in NL 00803.125.

C. When To Use

Use the following chart to choose the correct manual Notice of Overpayment form to send an overpaid individual.

IF THE RECIPIENT IS IN.... AND THEN USE FORM....
current pay does not reside in an institution where Medicaid pays more than half the cost of care SSA-L8170-U3 proposing full refund or recovery rate that is lesser of 10 percent total monthly income or full SSI check.
resides in an institution where Medicaid pays more than half the cost of care SSA-L8171-U3 proposing full refund or monthly installments.
nonpay status does not receive continuing title II benefits SSA-L8171-U3 proposing full refund or monthly installments.
receives continuing title II benefits SSA-L8172-U3 proposing full refund, monthly installments, or cross-program recovery.
To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900803110
NL 00803.110 - Notice of Overpayment Forms - 11/01/2007
Batch run: 09/19/2012
Rev:11/01/2007