TN 37 (07-24)
RFU001 REQUEST FOR REFUND - OVERPAID PERSON IN NONPAY STATUS NO CROSS PROGRAM ADJUSTMENT
POSSIBLE (A19) (G13)
(Requested/Generated)
Caption: How To Pay Us Back
You should refund this overpayment of (1) within 30 days. Please make your check or money order payable to “Social Security Administration,” and send it to us in the enclosed envelope. Always include (2) Social Security claim number on your check or money order.
If you cannot refund the full (3) now, please send:
-
-
•
An explanation of why you cannot pay the full amount now, and
-
•
A plan to repay the money
Fill-in values:
Fill-in (1) – Systems Generated (when it is not requested on the ENB) or Requested
As A Money Amount in Format $$$$$.¢¢
Overpayment Amount
Fill-in (2) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) Systems Generated (when it is not requested on the ENB) Requested As A
Money Amount in Format $$$$$.¢¢
Overpayment Amount
RFU007 SSI OFFSET NOT APPLICABLE (A59)
(Requested)
Caption: Your Benefits
Our records show that (1) did not get SSI money for (2) . So we can refund all of the Social Security money we held.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
RFU008 REFUND/RETURNED CHECK(S) USED TO REDUCE OVERPAYMENT (A34)
(Requested)
Caption: Your Benefits
We used the amount refunded to replace (1) the money we (2) (3) .
Fill-in values:
Fill-in (1) Requested As A One Position Alpha Character
Choice 1: (A) some of
Choice 2: (B) null
Fill-in (2) Requested As A One Position Alpha Character
Choice 1: (A) incorrectly paid
Choice 2: (B) overpaid
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Choice 4: Beneficiary's Name
RFU012 REQUEST FOR REFUND AND ADJUSTMENT PROPOSED — OVERPAID PERSON IN CURRENT PAY — OVERPAYMENT
EXCEEDS MONTHLY PAYMENT (A24)
(Requested/Generated)
Caption: How To Pay Us Back
You should refund this overpayment of $ (1) within 30 days. Please make your check or money order payable to the "Social Security
Administration," and send it to us in the enclosed envelope.
Always include (2) Social Security claim number on your check or money order.
If we do not receive your refund within 30 days, we will withhold 10 percent of (3) total monthly benefit or $10 (whichever is more) starting with the payment you will
receive (4) on or about (5) . We will continue withholding from (6) benefits until we recover the overpayment.
If you cannot refund the full overpayment now or cannot afford to have us withhold
10 percent of (7) benefit, you may ask us to hold back a smaller amount each month. Contact us to discuss
your plan for repaying the balance. You may need to show us proof of (8) assets, monthly income, and expenses. The minimum withholding amount we will accept
is $10.
Fill-in values:
Fill-in (1) - Systems Generated (when it is not requested on the ENB) or Requested
As A Money Amount in Format $$$$$.¢¢
Overpayment Amount
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: null
Choice 2: for him
Choice 3: for her
Fill-in (5) - Systems Generated (when it is not requested on the ENB) or Requested
As A Date In Format Shown Below
MM/DD/CCYY
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
RFU020 FOREIGN REFUND REQUEST NONPAY STATUS (F19)
Caption: How To Pay Us Back
(System Generated)
You should refund this overpayment within 30 days. Please make your check or money
order payable to "Social Security Administration," and send it to us in the enclosed
envelope. Always include (1) claim number on the check or money order. If you cannot refund the full (2) now, you should submit:
-
-
b.
an explanation of your financial circumstances, and
-
c.
a definite plan for repaying the balance.
If (3) pay us by check or money order, make sure that the check or money order is in United
States (U.S.) dollars or in local currency equal to U.S. dollars. When (4) pay us in local currency, we use the exchange rates in effect at the time we get
(5) payment. If this causes a difference between the amount (6) pay us and the amount (7) us, we will let you know. If you cannot mail (8) payment to us, please contact your Federal Benefits Unit. Visit (9) for a list of FBUs. If you are in Canada, visit (10) to find the office that services your area. They will help you make the refund.
If you have questions about Medicare, please visit (11) for information.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: Beneficiary's name possessive
Choice 2: your
Fill-in (2) Systems Generated
Overpayment amount in $$$$$¢¢
Fill-in (3) Systems Generated
Choice 1: you pay
Choice 2: he pays
Choice 3: she pays
Fill-in (4) Systems Generated
Choice 1: you pay
Choice 2: he pays
Choice 3: she pays
Fill-in (5) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (6) Systems Generated
Choice 1: you pay
Choice 2: he pays
Choice 3: she pays
Fill-in (7) Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes
Fill-in (8) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (9) Systems Generated
www.socialsecurity.gov/foreign/foreign.htm
Fill-in (10) Systems Generated
www.ssa.gov/foreign/canada.htm
Fill-in (11) Systems Generated
Medicare.gov
RFU036 REQUEST FOR REFUND AND ADJUSTMENT PROPOSED — OVERPAID PERSON IN CURRENT PAY — OVERPAYMENT
EXCEEDS MONTHLY PAYMENT (A24)
(Requested)
Caption: How To Pay Us Back
You should refund this overpayment of $ (1) within 30 days. Please make your check or money order payable to the "Social Security
Administration," and send it to us in the enclosed envelope.
Always include (2) Social Security claim number on your check or money order.
If we do not receive your refund within 30 days, we will withhold (3) full benefit starting with the payment you will receive (4) on or about (5) . We will continue withholding from (6) benefits until we recover the overpayment.
Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Overpayment Amount
Fill-in (2) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4) - Systems Generated
Choice 1: null
Choice 2: for him
Choice 3: for her
Fill-in (5) - Requested As A Date In Format Shown Below
MM/DD/CCYY
Fill-in (6) - Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her