Effective Dates: 07/12/2018 - Present Previous | Next

TN 74 (07-18)

NL 00703.700 Withdrawal — Repayment — NH

Document Identifier for Aurora: E3700

A. Exhibit letter

E3700.1 (Required)

If we approve (#1) request to withdraw (#2) claim for (#3), we will completely cancel the claim.

We can approve the withdrawal only if (#4) all the money paid from the claim. This includes any money we withheld from (#5) benefits.

If (#6) withdrawal request includes Medicare, (#7) must repay any costs for Medicare Part A (Hospital Insurance) services (#8) received.

What (#9) must repay

(#10) $ (#11)

(#12)

(#13)

E3700.1A

(Optional)

$ (#1) (#2)

E3700.1B

(Required)

(#14) $ (#15)

This means (#16) must repay us a total of $ (#17) before we can withdraw the claim.

E3700A (Optional)

However, you will not have to send us this entire amount. If we approve your withdrawal, you will become entitled to (#1) benefits based on your new application. Your new claim will be effective (#2) at the rate of $ (#3). We will use $ (#4) benefits accrued on your claim to reduce the amount you must repay.

E3700.2

(Required)

If you wish to withdraw (#1) claim, (#2) must send us a check or money order for $ (#3). Make the check or money order payable to the Social Security Administration. Be sure to write the Social Security Claim Number on (#4) payment.

Please mail (#5) payment to us using the enclosed refund envelope. Do not mail (#6) payment to the address at the top of this notice.

E3700B

(Required)

If you decide that you do not want to withdraw your claim, or if you have any questions, call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-(#3)(#4)(#5).

We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:

(#6)

(#7)

(#8)

(#9) (#10)-(#11)

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office.

Enclosure:

Refund envelope

B. Requesting instructions

  • •

    The request for this letter may be made on Form SSA-573 or SSA-559 by the claims authorizer or by the benefit authorizer. The authorizer will furnish the fill-in information and, if necessary, any additional paragraphs that may be needed.

  • •

    Use E3700A only when a new claim is filed with the withdrawal request and benefits will be paid.

  • •

    Use E3700.1, E3700B, and E3700.2 in all cases.

     

C. Fill-ins:

E3700.1
  1. 1. 

    your/Requestor’s Full Name (possessive)

  2. 2. 

    your/his/her/Beneficiary’s Full Name (possessive)

  3. 3. 

    A = retirement benefits
    B = disability benefits
    C = survivor’s benefits
    D = retirement benefits and Medicare
    E = disability benefits and Medicare
    F = survivor’s benefits and Medicare
    G = Medicare

  4. 4. 

    you repay/he repays/she repays

  5. 5. 

    your/his/her

  6. 6. 

    your/his/her

  7. 7. 

    you/he/she

  8. 8. 

    you/he/she

  9. 9. 

    you/he/she

  10. 10. 

    A = null
    B = The cost of the Medicare Part A services you received is
    C = The cost of the Medicare Part A services he received is
    D = The cost of the Medicare Part A services she received is

  11. 11. 

    Null/Amount

  12. 12. 

    A = null (if repayment is for Medicare only)
    B = You received, or will receive, Social Security benefits of:
    C = He received, or will receive, Social Security benefits of:
    D = She received, or will receive, Social Security benefits of:

  13. 13. 

    A = null (If repayment is for Medicare only)
    B = (Activate UTI E3700.1A Chart UTI)

E3700.1A
  1. 1. 

    Benefit amount

  2. 2. 

    Benefit month A/B, MM/YYYY, MM/YYYY
    A = MM/YYYY
    B = MM/YYYY through MM/YYYY

  3. 3. 

    Another Line? (Y/N)/NULL

E3700.1B
  1. 14. 

    A = NULL
    B = Amount already returned

  2. 15. 

    Amount refunded or NULL

  3. 16. 

    you/he/she

  4. 17. 

    Total amount to be repaid

E3700A
  1. 1. 

    Type of benefits, e.g. “retirement” or “disability”

  2. 2. 

    Month/Year benefits will be effective (MM/YYYY)

  3. 3. 

    Amount of monthly payment

  4. 4. 

    Amount of benefits accrued

E3700.2
  1. 1. 

    your/Name (possessive)

  2. 2. 

    you/he/she

  3. 3. 

    Total amount to be repaid

  4. 4. 

    your/his/her

  5. 5. 

    your/his/her

  6. 6. 

    your/his/her

E3700B
  1. 1. 

    Addressee zip code (5 digits)

  2. 2. 

    Addressee zip+4 (4 digits)

  3. 3. 

    Telephone area code (3 digit)

  4. 4. 

    Phone exchange (3 digit)

  5. 5. 

    Phone number (4 digit)

  6. 6. 

    Local office address line 1

  7. 7. 

    Local office address line 2

  8. 8. 

    Local office address line 3

  9. 9. 

    Local office city and state

  10. 10. 

    Local office zip code (5 digits)

  11. 11. 

    Zip+4 of local office (4 digits)

D. Typing instructions

Use Form SSA-L2000-C2. The typist should enclose a self-addressed envelope with the notice and the claim number should be written on the inside of the envelope below the flap.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0900703700
NL 00703.700 - Withdrawal — Repayment — NH - 07/12/2018
Batch run: 07/12/2018
Rev:07/12/2018