Our records show that you earned (1) .
If you disagree with (2) and you can show (3) wrong, please get in touch with any Social Security office and we will correct our
records.
(Optional)
A50
(Optional)
A52
Based on the earnings on our records, $ (4) should have been withheld from your benefits for (5) .
Based on this, you received $ (6) more in Social Security benefits than you were due.
How to Pay Us Back
3100A
or
3100B
or
3100G
If You Think You Should Not Have To Pay Us Back
3100C
If You Disagree With the Decision
3100D
If You Want Help With Your Appeal1
3100E
Your Responsibilities
3413D
If You Have Any Questions
3901C
Enclosures:
SSA-3105
Refund Envelope
1 If the person has an attorney, omit this paragraph.