The person making the waiver determination requests this notice and provides the appropriate fill-ins. We use this notice for Title II domestic disability cases, all Title II foreign cases, and Black Lung cases only. Refer to NL 00703.182 for Supplemental Security Income case.

We are writing to tell you that we are waiving the collection of *F1 *F2 overpayment of $*F3. This means *F4 will not have to pay this money back.

The Reason For Our Decision¹

For us to waive the collection of this overpayment, two things have to be true.

• •

  It was not *F5 fault that *F6 got too much *F7 money.

  AND

• •

  Paying us back would mean *F8 cannot pay *F9 bills for food, clothing, housing, medical care, or other necessary
  expenses, or it would be unfair for some other reason.

Based on the facts we have, we found that both of these are true about *F10. Therefore, *F11 will not have to pay us back. (E3180.1)

If You Disagree With The Decision (ALSC04)

If you do not agree with this decision, you have the right to appeal. We will review your case and look at any new facts you have. A person who did not make the first decision will decide your case. We will review the parts of the decision that you think are wrong and correct any mistakes. We may also review the parts of our decision that you think are right. We will make a decision that may or may not be in your favor.

• •

  You have 60 days to ask for an appeal in writing.

• •

  The 60 days 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 can file an appeal with any Social Security office. You must ask for an appeal in writing. Please use our "Request for Reconsideration" form, SSA-561. You may go to our website at *F1 to find the form SSA-561. You can also contact us by phone, mail, or come into an office to request the form. If you need help to fill out the form, we can help you by phone or in person. (ALS020) 

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 questions, you should contact *F1. You may also write to the Social Security Administration, P.O. Box 17769 Baltimore, Maryland 21235, U.S.A. Please be sure to include your claim number if you do write. However, if you visit an office, please take this letter. It will help the people there answer your questions. (3901D Foreign)

Or

Suspect Social Security Fraud?

Please visit http://oig.ssa.gov/report 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.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 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)

 

¹ Omit this caption and paragraph if collection of the overpayment is waived because of the $1,000 tolerance.  

E3180.1 Fill-Ins:

*F1-your, recipient/beneficiary's full name—possessive

*F2-Social Security, Black Lung

*F3-amount for which the beneficiary or recipient is liable minus the amount paid to date

*F4-you, he, she

*F5-your, his, her

*F6-you, he, she

*F7-Social Security, Black Lung

*F8-you, he, she

*F9-your, his, her

*F10-you, him, her

*F11-you, he, she

ALS020 Fill-Ins:

*F1-1 Always set to www.socialsecurity.gov
*F1-2 online

 

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