You offered to settle (1) $ (2) (3) overpayment by paying us $ (4) . We are writing to tell you that we will accept your offer as long as you send us the money by (5) . If you are late with your payment, you will have to pay back the full $ (6) .

 

How To Pay Us Back

To pay us back, send us a check or money order for $ (7) . Make your check or money order out to the Social Security Administration. Be sure to put (8) (9) , (10) on it. Please use the enclosed envelope to mail your check or money order to us.

 

3100FC (Foreign Cases Only):

 

If You Have Any Questions

3901C - Domestic

3901D - Foreign

 

Enclosure:

Refund Envelope

The recovery reviewer is responsible for requesting this notice and providing the appropriate fill-ins for SSA or BL cases.

See NL 00703.005E. for 3901C and D text. See NL 00703.100 for 3100FC text.

 

Fill-ins:

1. (1) 

   your, recipient/beneficiary's full name-possessive

2. (2) 

   amount of outstanding overpayment in the format, 499.25.

3. (3) 

   Social Security, Supplemental Security Income, Black Lung

4. (4) 

   amount of compromise offer

5. (5) 

   month, day, year that compromise payment is due in the format July 30, 1986

6. (6) 

   amount of overpayment

7. (7) 

   amount of compromise offer

8. (8) 

   your, beneficiary or recipient's first name (possessive) if a child. If adult, use “Mr.” or “Ms.” last name (possessive).

9. (9) 

   claim number (Title II), Social Security number (Title XVI)

10. (10) 

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

Use Form SSA-L2000-C2 (Universal Notice) and follow the notice standards for cases processed in the PC. 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.