When (1) received (2) benefits on (3) Social Security record, (4) was overpaid
$ (5) . In a letter we sent earlier, we told you (6) how this overpayment happened and about (7) right to question our decision about the overpayment.

(8) still owe us $ (9) . We are writing to tell you how to pay this money back. This letter will also tell you what to do if you think the overpayment was not (10) fault or if (11) cannot afford to pay us back.

3102A
OR
3102C

You 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 is not (12) fault in any way, and

2. (2) 

   (13) could not meet (14) 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 (15) 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 payment 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. (16) 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 (Request for Waiver of Overpayment Recovery or Change in Repayment Rate). Even if you do not want to request waiver, please call, write, or visit any Social Security office¹ if (17) cannot afford the planned withholding of (18) payment. Please take this letter with you if you do visit an office. Unless we hear from you within 30 days, we will withhold (19) payment as shown above.

 

If You Have Any Questions

3901C - Domestic
3901D - Foreign

 

Enclosure:

Refund Envelope

 

¹ If the person lives outside the U.S., substitute a fill-in from paragraph 3901D in NL 00703.005E.

• •

  Send when processing a terminated overpayment collection case and the overpayment is equal to or more than the current monthly payment. Send this notice to the representative payee.

• •

  Use paragraph 3102A if the overpayment is more than the monthly payment

• •

  Use paragraph 3102C if the overpayment is equal to the monthly payment.

• •

  Refer to NL 00703.005E. for 3901C and 3901D text and fill-ins.

• •

  Refer to NL 00703.102 for 3102A and 3102C text and fill-ins.

   

Fill-ins:

1. (1) 

   full name of overpaid beneficiary.

2. (2) 

   Type of benefit to which the beneficiary was previously entitled, in the format, “husband's” or widow's.”

3. (3) 

   Name of the wage earner on whose record the overpayment happened, possessive case. Use the format, “John Smith's.”

4. (4) 

   If the beneficiary is a child, show the child's first name. If the beneficiary is an adult, show either Mr. or Ms. and the beneficiary's last name. If the beneficiary's last name and sex are the same as the wage earner's, show the beneficiary's full name.

5. (5) 

   Original overpayment amount

6. (6) 

   him, her

7. (7) 

   his, her

8. (8) 

   If the beneficiary is a child show the first name; if an adult, show Mr. or Ms. and the last name.

9. (9) 

   Current overpayment amount.

10. (10) 

    his, her

11. (11) 

    he, she

12. (12) 

    If the beneficiary is a child, show the first name of beneficiary, possessive case. If the beneficiary is an adult, show Mr. or Ms. and the last name, possessive case.

13. (13) 

    He, She

14. (14) 

    his, her

15. (15) 

    If the beneficiary is a child, show the first name of beneficiary, possessive case. If the beneficiary is an adult, show Mr. or Ms. and the last name, possessive case.

16. (16) 

    If the beneficiary lives outside the U.S., omit next two sentences.

17. (17) 

    he, she

18. (18) 

    his, her

19. (19) 

    his, her

Use Form SSA-L2000-C2 (Universal Notice) and follow notice standards. Information for this notice will be shown on Form SSA-573