When a manual notice is required per NL 00801.010A., the field office is responsible for requesting this notice and provides the appropriate fill-ins. We use this notice in Supplemental Security Income cases only. Refer to NL 00703.180 for the Title II and Black Lung waiver notices and for ALS020 text.

We are writing to tell you that we are waiving the collection of (1) Supplemental Security Income (SSI) overpayment of $ (2) . This means (3) will not have to pay this money back.

 

The Reason For Our Decision

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

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  It was not (4) fault that (5) got too much SSI money.

AND

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  Paying us back would mean (6) cannot pay (7) 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 8 . Therefore,
(9) will not have to pay us back.

 

If You Disagree With The Decision (ALC04)

ALS020

 

How To Appeal:

There are two ways to appeal. You can pick the one you want. If you meet with us in person, it may help us decide (10) case.

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  Case Review. You have the right to review the facts in (11) file. You can give us more facts to add to (12) file. Then we will decide (13) case again. You will not meet with the person who decides (14) case.

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  Informal Conference. You will meet with the person who decides (15) case. You can tell that person why you think you are right. You can give us more facts to help prove you are right. You can bring other people to help explain (16) case.

 

If You Have Any Questions

CTDO 

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  your, recipient/beneficiary's full name—possessive

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

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  you, he, she

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  your, his, her

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  you, he, she

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  you, he, she

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  your, his, her

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  you, him, her

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  you, he, she

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  your, recipient's first name, possessive, if child; if an adult, “Mr.” or “Ms.” last name—possessive

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  your, his, her

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  your, his, her

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  your, his, her

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  your, his, her

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  your, his, her

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