We previously notified you that you were overpaid. The amount of your overpayment is now $ (1) .

 

How To Pay Us Back

3100A

or

3104B

or

3100B

You or your representative have the right to request a determination concerning the need to recover the overpayment. This is called waiver. You may request waiver at any time. A request for waiver will be approved if both of the following are true:

1. 1. 

   The overpayment was not your fault in any way, and

2. 2. 

   You could not meet your necessary living expenses if we recovered the overpayment, or recovery would be unfair for some other reason.

If you request waiver, we may need a statement of your assets and monthly income and expenses.

We will notify you in writing of our determination.

If you request waiver within 30 days of the date of this notice, we will not take any action to recover the overpayment unless waiver is denied after you have had opportunity for a personal conference.

If you request waiver after 30 days, the action to recover the overpayment as indicated above will be stopped and any payments withheld on or after the date of your request will be paid back to you. We will not resume any recovery action unless you are denied waiver after you have had opportunity for a personal conference.

If you request waiver and after reviewing your request we cannot approve it, we will notify you in writing of our reasons.¹ A personal conference with a Social Security employee will then be scheduled for you so that you can explain why you do not believe your waiver request should be denied. More information about the personal conference is given in the notice if we cannot waive recovery of your overpayment.

If you disagree with the waiver decision you have other appeal rights. These appeal rights will also be explained in detail in the waiver determination notice.

If you request waiver, you will be asked when you contact a Social Security office to complete Form SSA-632-BK (Overpayment Recovery Questionnaire).

 

 

If You Have Any Questions

3901C

 

Enclosure:

Refund envelope²

 

¹ If the person lives outside the U.S., omit the next 2 sentences.

² If the overpayment is less than the monthly payment, omit refund envelope and reference to enclosure.

The person who decides that adjustments must be proposed (generally the benefit authorizer) name is responsible for requesting this notice and providing the appropriate fill-ins.

• •

  Use 3100A if the overpayment exceeds the monthly payment.

• •

  Use 3104B if the overpayment equals the monthly payment.

• •

  Use 3100B if the overpayment is less than the monthly payment.

• •

  Use 3114A and 3901C for domestic cases.

• •

  Use 3114B if the person lives outside the U.S.

   

Refer to NL 00703.100 for 3100A, 3100B text and fill-ins. Refer to NL 00703.104 for 3104B text and fill-ins.

 

Fill-in:

1. (1) 

   amount

    

Because the fill-ins may vary according to the different situations, follow the requester's typing instructions carefully.