Our records show that you earned $ (1) in (2) . We assume that you worked in all months in (3) after you became entitled to Social Security benefits.
(Optional)
3417C
If you disagree with (4) and you can show (5) wrong, or if you did little or no work in (6) after you became entitled to Social Security benefits, please get in touch with any
Social Security office and we will correct our records.
(Optional)
A50
(Optional)
A52
Based on the information we have now, $ (7) should have been withheld from your benefits for (8) .
Based on this, you received $ (9) more in Social Security benefits that 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
Information About Work and Earnings
3417B
Your Responsibilities
3413D
If You Have Any Questions
3901C
Enclosures:
Form SSA-3105
Refund envelope
1 If the person has an attorney, omit this paragraph.