You received $*F1 more in *F2 benefits *F3 than *F4 due.

 

*F5 (OPT188)

 

You must repay the money overpaid to *F1 unless you spent the money for *F2 benefit and the overpayment was not your fault. (OPT189)

 

How to Pay Us Back

 

Please refund this overpayment within 30 days. Make your check or money order payable to the "Social Security Administration." Include the Social Security Claim Number on the check or money order, and send it to us in the enclosed envelope.

*F1

If we do not receive *F2 refund within 30 days, we will withhold 10 percent of *F3 payments until we recover the overpayment. We will do this starting with the payment *F4 will normally receive about *F5. (3110A)

 

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 *F1 about *F2. The reduced payment will be $*F3 and you will receive the regular monthly payment about *F4. (3110B)

 

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. We assume you got this letter 5 days after the date on it, unless you show us that you did not get it within the 5-day period.

• •

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

• •

  You have to ask for an appeal in writing. We will ask you to sign a form called "Request for Reconsideration." The form number is SSA-561-U2. To get this form, contact one of our offices. We can help you fill out the form.

 

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

Even if you do not want to request reconsideration or waiver, call us at 1-800-772-1213 if you think you are not liable for repayment or if withholding of the monthly payment will cause hardship. Unless we hear from you within 30 days, we will withhold the benefit as shown above. (3108A Domestic)

 

Or

 

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 Want Help With Your Appeal¹ (REPC01)

 

You may choose to have a representative help you. We will work with this person just as we would work with you. If you decide to have a representative, you should find one quickly so that person can start preparing your case.

Many representatives charge a fee only if you receive benefits. Others may represent you for free. Usually, your representative may not charge a fee unless we approve it. Your local Social Security office can give you a list of groups that can help you find a representative.

If you get a representative, you or that person must notify us in writing. You may use our Form SSA-1696 "Appointment of Representative." Any local Social Security office can give you this form. (REP002)

 

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)

 

Or

 

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 Any Questions

We invite you to visit our website at www.socialsecurity.govv 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 1-*F3- *F4- *F5. 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:

*F6

*F7

*F8

*F9 *F10- *F11

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. (CTDO Domestic)

 

Enclosures (2):

Refund envelope

SSA-3105

 

 

¹If the person lives outside the U.S. or has an attorney omit this paragraph.

 

 

The person who determines the overpayment (generally the benefit authorizer) is responsible for requesting this notice and providing the appropriate fill-ins. If the overpayment computation is too complex for a simple narrative explanation, use a chart such as the following:

 

 

OPT188 Fill-Ins:

*F1-1 Amount of overpayment

*F2-1 Social Security

*F2-2 Black Lung

*F3-1 for (Name of beneficiary)

*F3-2 leave blank

*F4-1 he was

*F4-2 she was

*F4-3 you were

*F5-1 explanation of overpayment 

 

OPT189 Fill-Ins:

*F1-1 Beneficiary Name

*F2-1 his

*F2-2 her

 

You must select one of the following UTIs:

• •

  Use UTI 3110A if the overpayment exceeds the monthly payment.

• •

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

• •

  Use UTI 3110B if the overpayment is less than the monthly payment.

3110A Fill-Ins:

*F1-1 Optional #3100FC if person outside U.S.

*F2-1 your

*F2-2 name of beneficiary

*F3-1 your

*F3-2 his

*F3-3 her

*F4-1 you

*F4-2 he

*F4-3 she

*F5-1 MM/DD/CCYY

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, YYYY

 

3110B Fill-Ins:

*F1-1 you would normally receive

*F1-2 you would normally receive for (name 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

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

 

You must select one of the following UTIs:

• •

  Use UTI 3108A and CTDO if the person lives in the U.S.

• •

  Use UTI 31000F and REF197 if the person lives outside the U.S.

3100F:

*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

CTDO (Domestic) Fill-Ins:

*F1-1 Zip code

*F2-1 Zip+4

*F2-2 DO Code

*F3-1 Telephone Area Code

*F4-1 Phone Exchange

*F5-1 Phone Number

*F6-1 Local Office Address Line #1

*F7-1 Local Office Address Line #2

*F8-1 Local Office Address Line #3

*F9-1 City & State of Local Office

*F10-1 Local Office Zip code

*F11-1 Zip+4 of Local Office