TN 113 (07-24)

NL 00703.103 Notice To Overpaid Person In Nonpay Status But Receiving Benefits For Other Beneficiary In Same Household — Refund Requested And Adjustment Proposed — Alien Tax Withholding Involved

Document Identifier for Word Processor: E3103

A. Exhibit Letter

We sent you $ (*F1) more in Social Security benefits than we should have.

(*F2) . (E3103.1)

How To Pay Us Back

You should refund this overpayment within 30 days. Please make your check or money order payable to the “Social Security Administration” and send it to us in the enclosed envelope. Always include *F1 Social Security claim number on the check or money order. If you cannot refund the *F2 now, you should give us: (a) a partial payment; (b) an explanation of *F3 assets and income and expenses; and (c) a definite plan for repaying the rest of the money.

Please send your check or money order in United States (U.S.) currency or in local currency equal to the United States dollars. When you pay us in local currency, we use the exchange rate in effect at the time we receive *F4 payment. If this causes a difference between the amount you pay us and the amount *F5 owe us, we will let you know. If you cannot mail *F6 payment directly to us, please go to your nearest Federal Benefits Unit (FBU) for help in making the refund. Visit *F7 for a list of FBUs. If you are in Canada, visit *F8 to find the office that services your area.

If we do not receive *F9 refund within 30 days, we plan to recover the overpayment by withholding 10 percent of *F10 benefit beginning with the payment you will receive for *F11 on or about *F12. We will continue withholding 10 percent of the benefit you receive for *F13 until the amount we have kept is equal to the amount you owe us. (3103A) 

Or

To recover the overpayment, we will withhold 10 percent of the payment you will receive *F1 until we recover the overpayment. We will do this starting with the payment *F2 will receive on or about *F3. (3104B)

Or

We plan to recover the overpayment from the payment you would normally receive for *F1 about *F2. The reduced payment will be $*F3 and you will receive the regular monthly payment about *F4. (3102B)

If You Think You Should Not Have To Pay Us Back

You may not have to pay us back. Sometimes we can waive the collection of an overpayment, which means you will not have to pay us back. For us to waive the collection of your overpayment, two things must be true.

  • It was not your fault that you got too much Social Security money.

AND

  • Paying us back would mean you cannot pay your bills for food, clothing, housing, medical care, or other necessary expenses, or it would be unfair for some other reason.

You can ask for waiver at any time by filling out the waiver form. The form number is SSA-632-BK. We will not collect the overpayment while we decide if we can waive collection. If you ask for waiver in the next 30 days, we will not withhold benefits until we decide if we can waive collection.

You may need to show us proof of your monthly income, expenses, and assets. Examples are pay stubs, pension records, rent receipts, utility bills and bank statements.

If you have any questions, you may contact *F1. (3100C)

 

If You Disagree With The Decision

If you disagree with the decision, you have the right to appeal. A person who did not make the first decision will decide your case. We will review your case again and consider any new facts you have.

  • You have 60 days to ask for an appeal. If you ask in the next 30 days, you will not have to pay us back until we decide your case.

  • Both the 30- and 60-day periods start the day after you receive this letter.

  • You must have a good reason if you wait more than 60 days to ask for an appeal.

  • Your request must be in writing. The fastest and easiest way to file an appeal is to visit *F1 online.

We are enclosing a pamphlet called “Important Information About Your Appeal and Waiver Rights.” Please be sure to read it.

If withholding the monthly payment will cause hardship, please contact *F2.

You can contact us even if you do not want to request a reconsideration or a waiver. Please take this letter with you if you do visit an office. Unless we hear from you within 30 days, we will withhold the benefit as shown above. (3100F Foreign)

If You Have Any Questions (REFC01)

Need more help?

1. Visit www.ssa.gov for fast, simple, and secure online service.

2. If you are in the United States, American Samoa, Guam, Northern Mariana Islands, Puerto Rico, or the U.S. Virgin Islands, call us at 1-800-772-1213. If you are deaf or hard of hearing, call TTY 1-800-325-0778.

3. You may also call your local Social Security office.

  • If you are in Canada, visit *F1 to find the office that services your area.

  • Contact your nearest Federal Benefits Unit (FBU). Visit *F2 for a list of FBUs.

  • Write to the Social Security Administration at:

    P.O. Box 17769

    Baltimore, Maryland, 21235-7769

    USA

If you contact us, please refer to this letter. It will help us answer your questions.

How are we doing? Go to www.ssa.gov/feedback to tell us. (REF197)

Enclosures (2):

Form SSA-3105

Refund envelope

 

B. Requesting Instructions

The person who determines the overpayment (generally the benefit authorizer) is responsible for requesting this notice and providing the appropriate fill-ins.

  • Use 3103A if the overpayment exceeds the monthly payment.

  • Use 3104B if the overpayment equals the monthly payment.

  • Use 3102B if the overpayment is less than the monthly payment.

  • Use 3100C and 3100F in all cases.

     

E3103.1 Fill-Ins:

*F1-1 Amount of overpayment (not including taxes withheld)

*F2-1 Explanation of the overpayment (a chart may be included following the explanation)

3103A Fill-Ins:

*F1-1 your

*F1-2 Beneficiary’s name possessive

*F2-1 $$ amount of the overpayment

*F3-1 your

*F3-2 his

*F3-3 her

*F4-1 your

*F4-2 his

*F4-3 her

*F5-1 you owe

*F5-2 he owes

*F5-3 she owes

*F6-1 your

*F6-2 his

*F6-3 her

*F7-1 www.socialsecurity.gov/foreign.htm

*F8-1 www.ssa.gov/foreign/canada.htm

*F9-1 your

*F9-2 his

*F9-3 her

*F10-1 your

*F10-2 Beneficiary’s name possessive

*F11-1 you

*F11-2 him

*F11-3 her

*F12-1 MM/DD/CCYY (Instructional text and not part of the notice language: date payment would have been received)

*F13-1 Beneficiary’s name

3102B Fill-Ins:

*F1-1 Name(s) of beneficiary

*F2-1 MM/DD/YYYY payment will be received

*F3-1 Amount of payment

*F4-1 MM/DD/YYYY payment will be received

3104B Fill-Ins:

*F1-1 for him

*F1-2 for her

*F1-3 leave blank

*F2-1 you

*F2-2 he

*F2-3 she

*F3-1 Month DD, CCYY

3100C Fill-Ins:

*F1-1 your nearest Social Security office

*F1-2 the Social Security office that services your area in Canada. To find which office services your area, visit www.ssa.gov/foreign/canada.htm online

*F1-3 your nearest Federal Benefits Unit (FBU). Visit www.ssa.gov/foreign/foreign.htm for a list of FBUs

3100F Fill-Ins:

*F1-1 www.ssa.gov/benefits/disability/appeal.html

*F2-1 your nearest Social Security office

*F2-2 the Social Security office that services your area in Canada. To find which office services your area, visit www.ssa.gov/foreign/canada.htm online

*F2-3 your nearest Federal Benefits Unit (FBU). Visit www.ssa.gov/foreign/foreign.htm for a list of FBUs

REF197 Fill-Ins:

*F1-1 http://www.socialsecurity.gov/foreign/canada.htm

*F2-1 http://www.socialsecurity.gov/foreign/foreign.htm


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900703103
NL 00703.103 - Notice To Overpaid Person In Nonpay Status But Receiving Benefits For Other Beneficiary In Same Household — Refund Requested And Adjustment Proposed — Alien Tax Withholding Involved - 07/10/2024
Batch run: 07/10/2024
Rev:07/10/2024