We are writing to you about an overpayment (1) us. The amount of the overpayment is $ (2) .

We have written to you about this before, but you have not settled this matter. You should repay this overpayment now, or contact us about how you will pay us back.

 

If We Do Not Hear From You

If you do not pay us or get in touch with us about this overpayment by (3) , we will consider sending (4) case to the Department of Justice.

If we do this, the Department of Justice might take you to court to collect the overpayment. If that happens and the court decides against you, you might have to pay both the overpayment and court costs.

 

Please Get In Touch With Us Now

Please get in touch with us now if (5) can not afford to pay all the money (6) us. In some situations we will settle for less than the full amount (7) us. We call this a compromise settlement.

Contact us for more information about this kind of settlement. Of course, if we accept your offer, we will not refer (8) case to the Justice Department.

 

How To Pay Us Back

Call us at (9) now if you want to pay back all or part of the money (10) us. Then send us a check or money order made out to the Social Security Administration. Be sure to put (11) , (12) on it. Please use the enclosed envelope to mail your check or money order to us.

 

If You Have Any Questions

3901C

 

Enclosure:

Refund Envelope

Use this notice in lieu of the SSA-L4940 for DOJ referral cases. (FO's without wordprocessors can continue to use the form letter.)

 

Fill-ins:

1. (1) 

   you owe, beneficiary/recipient full name owes

2. (2) 

   amount of outstanding overpayment in the format, 499.25.

3. (3) 

   contact date in the format, June 6, 1986.

4. (4) 

   your, his, her

5. (5) 

   you, beneficiary or recipient's first name, if child. If adult, use “Mr.” or “Ms.” and last name.

6. (6) 

   you owe, he owes, she owes

7. (7) 

   you owe, he owes, she owes

8. (8) 

   your, his, her

9. (9) 

   Toll free telephone number

10. (10) 

    you owe, beneficiary or recipient first name (of child) owes, or “Mr.” or “Ms.” last name owe.

11. (11) 

    your claim number, his claim number, her claim number if Title II, your Social Security number, his Social Security number, her Social Security number if title XVI

12. (12) 

    Actual Social Security number and symbol of the record on which the overpayment exists.

     

Refer to NL 00703.005E. for 3901C text.

Use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards. Because the requested fill-ins and paragraphs may vary according to the different situations, follow the requester's instructions carefully. There is a refund envelope enclosure. Include a “refund envelope” with the letter and type the claim number on the inside of the envelope below the flap. Place the envelope lengthwise on the left-hand side of the notice and staple in the upper left-hand corner.