OPTC01 – CAPTION
Overpayment Information
OPT029 – NEW OVERPAYMENT – OVERPAYMENT NOT DUE TO TERMINATION
We paid (1) (2) for (3). Since we should have paid (4) (5) for (6), we paid (7) (8)
more than (9) (10) due.
Fill-in values:
|
|
Fill-in (1) |
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
|
Choice 2
|
you
|
Fill-in (2)
|
Sum of the Monthly Benefit Credited (MBCs) on the Pre-MBR starting with the internal
Business Start Date and ending with Current Operating Month (COM) minus 1 month in
the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
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Internal Business Start Date in format Month CCYY
|
Choice 2
|
Internal Business Start Date plus “and” plus Current Operating Month (COM) minus 1
month in the format Month CCYY
|
Choice 3
|
Internal Business Start Date plus “through” plus Current Operating Month (COM) minus
1 month in the format Month CCYY
|
Fill-in (4)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
Fill-in (5)
|
Sum of the Monthly Benefit Credited (MBCs) on the Pre-MBR starting with the internal
Business Start Date and ending with Current Operating Month (COM) minus 1 month in
the format $$$$$.¢¢
|
Fill-in (6) |
|
Choice 1
|
Internal Business Start Date in format Month CCYY
|
Choice 2
|
Internal Business Start Date plus “and” plus Current Operating Month (COM) minus 1
month in the format Month CCYY
|
Choice 3
|
Internal Business Start Date plus “through” plus Current Operating Month (COM) minus
1 month in the format Month CCYY
|
Fill-in (7)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
Fill-in (8)
|
Difference between Trigger Record New Overpayment Amount (TR-NEW-OPA-AMOUNT) and total
Trigger Record Other Beneficiary Overpayment Amount (TR-OTH-BENE-OPA) in the format
$$$$$.¢¢
|
Fill-in (9)
|
|
Choice 1
|
he
|
Choice 2
|
she
|
Choice 3
|
you
|
Fill-in (10)
|
|
Choice 1
|
was
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Choice 2
|
were
|
OPT064 – EXPLAINS TO A WORKING BENEFICIARY THERE IS AN OVERPAYMENT ON HIS OR HER
RECORD FOR ONE YEAR BECAUSE THE EARNINGS THEY REPORTED IS DIFFERENT FROM WHAT SSA
RECORDS SHOW
We recently found that the earnings (1) for (2) and the earnings information we have
do not match. (3) told us (4) earned (5) in (6) but our records show that (7) earned
(8). If our records are correct, we paid (9) (10) too much.
Fill-in values
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|
Fill-in (1)
|
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Choice 1
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"reported for” plus Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
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Choice 2
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“reported for you”
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Fill-in (2)
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Year in the format CCYY
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Fill-in (3)
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Choice 1
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
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Choice 2
|
You
|
Fill-in (4)
|
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Choice 1
|
he
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Choice 2
|
she
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Choice 3
|
you
|
Fill-in (5)
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Amount of reported earnings (AORE)
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Fill-in (6)
|
Year of Earnings Report (YOER) in the format CCYY
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Fill-in (7)
|
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Choice 1
|
he
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Choice 2
|
she
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Choice 3
|
you
|
Fill-in (8)
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Amount of reported earnings (AORE)
|
Fill-in (9)
|
|
Choice 1
|
him
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Choice 2
|
her
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Choice 3
|
you
|
Fill-in (10)
|
Overpayment amount
|
OPT065 – EXPLAINS TO A WORKING BENEFICIARY THAT BECAUSE THE EARNINGS PREVIOUSLY
POSTED FOR MULTIPLE YEARS ARE LESS THAN THE EARNINGS ON THE MASTER EARNINGS RECORD,
THERE ARE OVERPAYMENTS FOR MULTIPLE YEARS
We recently found that the earnings reported for (1) for the years shown below and
the earnings on our records do not match. If our records are correct, we paid (2)
(3) too much.
Fill-in values:
|
|
Fill-in (1)
|
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Choice 1
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
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Choice 2
|
you
|
Fill-in (2)
|
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Choice 1
|
you
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Choice 2
|
him
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Choice 3
|
her
|
Fill-in (3)
|
Overpayment amount in the format $$$$$.¢¢
|
OPT084 – EXPLAINS TO A WORKING BENEFICIARY THAT BECAUSE THE EARNINGS PREVIOUSLY
POSTED FOR A SINGLE YEAR ARE LESS THAN THE EARNINGS ON THE MASTER EARNINGS RECORD
AND NO BENEFITS WERE WITHHELD FOR THIS YEAR, THERE IS AN OVERPAYMENT FOR JUST ONE
YEAR
Our records show that (1) had earnings in (2) of (3) that we did not consider when
we paid (4). If our records are correct, we paid (5) (6) too much.
Fill-in values:
|
|
Fill-in (1)
|
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Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
|
Choice 2
|
you
|
Fill-in (2)
|
Year of Earnings Report (YOER) in the format CCYY
|
Fill-in (3)
|
Amount of reported earnings (AORE)
|
Fill-in (4)
|
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Choice 1
|
him
|
Choice 2
|
her
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Choice 3
|
you
|
Fill-in (5)
|
|
Choice 1
|
him
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Choice 2
|
her
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Choice 3
|
you
|
Fill-in (6)
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Overpayment amount
|
OPT085 – TELLS THE BENEFICIARY THE OVERPAYMENT AMOUNT
(1), (2) us (3).
Fill-in values:
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Fill-in (1)
|
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Choice 1
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After all the changes (use when earnings caused more than 1 adjustment)
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Choice 2
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As a result (use when earnings caused a single adjustment)
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Fill-in (2)
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Choice 1
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you owe
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Choice 2
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “owes”
|
Fill-in (3)
|
Total overpayment amount due in $$$$$.¢¢ format
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OPT086 – EARNINGS PREVIOUSLY POSTED FOR MULTIPLE YEARS ARE LESS THAN THE
EARNINGS ON THE MASTER RECORD AND NO BENEFITS WERE WITHHELD, THEREFORE, THERE ARE
OVERPAYMENTS FOR EACH YEAR
Our records show that (1) had earnings for the years shown below that we did not consider
when we paid (2). If our records are correct, we paid (3) (4) too much.
Fill-in values:
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|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
|
Choice 2
|
you
|
Fill-in (2)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
Fill-in (3)
|
|
Choice 1
|
him
|
Choice 2
|
her
|
Choice 3
|
you
|
Fill-in (4)
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Total overpayment amount
|
OPT087 – CHART HEADING UTI THAT PROVIDES THE WORKING BENEFICIARY THE EARNINGS
POSTED WITH NO BENEFITS PREVIOUSLY WITHHELD FOR THAT YEAR EARNINGS
Earnings On
Year Our Records
OPT088 – EXPLAINS TO A WORKING BENEFICIARY IN A CHART THE EARNINGS POSTED WHEN
NO BENEFITS WERE PREVIOUSLY WITHHELD FOR THESE EARNINGS
(1) (2)
Fill-in values:
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|
Fill-in (1)
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Year of Earnings Report (YOER) in format CCYY
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Fill-in (2)
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Amount of reported earnings (AORE)
|
OPT096 – PRIOR OVERPAYMENT WITH A PROTEST AND PROTEST DECISION STILL
PENDING
We already told you that we paid (1) (2) too much for a past period. We will send
you another letter to let you know what we will do about the recovery of that money.
Fill-in values
|
|
Fill-in (1)
|
|
Choice 1
|
you
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
|
Fill-in (2)
|
|
Choice 1
|
Due process overpayment amount in the format $$$$$.¢¢
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Choice 2
|
Null
|
OPT097 – RECOVERY OF AN INCORRECT PAYMENT
Once we get back the money (1) not due for this year, we will start to withhold (2)
benefits to get back the other money (3).
Fill-in values
|
|
Fill-in (1)
|
|
Choice 1
|
you were
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Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “was”
|
Fill-in (2)
|
|
Choice 1
|
your
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Choice 2
|
his
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Choice 3
|
her
|
Fill-in (3)
|
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Choice 1
|
you owe
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Choice 2
|
he owes
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Choice 3
|
she owes
|
OPT107 – FULL OR PARTIAL WITHHOLDING FOR ONE MONTH
We will withhold 10 percent from (1 ) (2) payment to start recovering the money we
(3) (4). This is the payment you will receive on or about (5). The minimum we will
withhold is $10. If the total benefit is less than $10, we will withhold the entire
benefit.
Fill-in values:
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|
|
|
|
|
|
|
|
|
|
|
|
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Fill-in
(1)
|
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Choice 1
|
your
|
Choice 4
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Fill-in
(2)
|
Date of overpayment recovery in the format Month CCYY
|
Fill-in
(3)
|
|
Choice 1
|
overpaid
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Choice 2
|
incorrectly paid
|
Fill-in
(4)
|
|
Choice 1
|
you
|
Choice 2
|
him
|
Choice 3
|
her
|
Fill-in
(5)
|
Date the overpayment will be deducted in the format Month DD, CCYY
|
OPT122 – NEW OVERPAYMENT DUE TO RETROACTIVE TERMINATION
Since we did not stop (1) payments until (2), (3) paid (4) too much in benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
Fill-in (2)
|
Current Operating Month (COM) in format Month CCYY
|
Fill-in (3)
|
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Choice 1
|
he was
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Choice 2
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she was
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Choice 3
|
you were
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Fill-in (4)
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New overpayment amount in $$$$$.¢¢
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OPT123 – TOTAL OVERPAYMENT INCLUDES PRIOR OVERPAYMENT
(1) total overpayment of (2) includes (3) prior overpayment.
Fill-in values:
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|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
Your
|
Fill-in (2)
|
Due Process Overpayment (DPO) on the Post-MBR in format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
his
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Choice 2
|
her
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Choice 3
|
your
|
OPT125 – BENEFICIARY'S OVERPAYMENT BEING RECOVERED FROM ANOTHER
AUXILIARY
We paid other person(s) on this record (1) more in benefits than we should have. Under
Social Security law, you are responsible for this overpayment.
Fill-in values:
|
|
Fill-in (1)
|
Other beneficiary's overpayment amount in format $$$$$.¢¢
|
OPT127 – ADVISES OF OVERPAYMENT RECOVERY AMOUNT (OPRA) ON POST-MBR
We used (1) of (2) benefits to recover (3) of an overpayment on this record.
Fill-in values:
|
|
Fill-in (1)
|
Overpayment Recovery Amount (OPRA) on Post-MBR in format $$$$$$.¢¢
|
Fill-in (2)
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Choice 1
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Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
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Choice 2
|
your
|
Fill-in (3)
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Choice 1
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all
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Choice 2
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part
|
OPT128 – BENEFICIARY’S NEW OVERPAYMENT, BENEFICIARY’S PRIOR OVERPAYMENT AND
ANOTHER BENEFICIARY’S OVERPAYMENT
(1) total overpayment of (2) includes (3) prior overpayment and another beneficiary's
overpayment that (4) (5) liable for under Social Security law.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Fill-in (2)
|
Due Process Overpayment (DPO) amount on the Post-MBR in format $$$$$.¢¢
|
Fill-in (3)
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|
Choice 1
|
his
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Choice 2
|
her
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Choice 3
|
your
|
Fill-in (4)
|
|
Choice 1
|
he
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Choice 2
|
she
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Choice 3
|
you
|
Fill-in (5)
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Choice 1
|
is
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Choice 2
|
are
|
OPT131 – REMAINING BALANCE ON PRIOR OVERPAYMENT
(1) (2) an outstanding balance remaining on a prior overpayment. That remaining balance
is (3).
Fill-in values:
|
|
Fill-in (1) |
|
Choice 1 |
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive) |
Choice 2 |
You |
Fill-in (2) |
|
Choice 1 |
has |
Choice 2 |
have |
Fill-in (3)
|
Show the remaining overpayment amount or the old overpayment amount in format $$$$$$.¢¢
|
OPT132 – PIC A (H) DIES OR PIC B DIES AND HAVE JOINT BANK DATA ON MBR AND THERE
IS AN OVERPAYMENT
We paid (1) more in benefits than we should have. We deposited (2) benefits for (3)
into a bank account which (4) also owned. We can't pay benefits for the month of death,
(5), or later. Because (6) a joint owner of the bank account, (7) overpaid (8).
Fill-in values:
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|
Fill-in (1)
|
|
Choice 1
|
New overpayment amount
|
Fill-in (2)
|
|
Choice 1
|
NH-FULL name (possessive) when PIC A died and PIC B is responsible for the overpayment
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) when
PIC B died and PIC A is responsible for the overpayment
|
Fill-in (3)
|
|
Choice 1
|
Beneficiary's date of death when Beneficiary Date of Death (BDOD) = Current Operating
Month (COM) minus 1 month
|
Choice 2
|
Beneficiary's date of death plus “and” plus the Current Operating Month (COM) minus
1 month when the Beneficiary Date of Death (BDOD) = Current Operating Month (COM)
minus 2 months
|
Choice 3
|
Beneficiary's date of death plus “through” plus Current Operating Month (COM) minus
1 month when the Beneficiary Date of Death (BDOD) > Current Operating Month (COM)
minus 2 months
|
Fill-in (4)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
|
Choice 2
|
you
|
Fill-in (5)
|
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Choice 1
|
Beneficiary Date of Death (BDOD) for PIC A in the format Month CCYY
|
Choice 2
|
Beneficiary Date of Death (BDOD) for PIC B in the format Month CCYY
|
Fill-in (6)
|
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Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “is”
|
Choice 2
|
you are
|
Fill-in (7)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) plus “is”
|
Choice 2
|
you are
|
Fill-in (8)
|
|
Choice 1
|
Trigger Record New Overpayment Amount (WS-TR-NEW-OPA) in the format $$$$$.¢¢
|
Choice 2
|
Trigger Record Other Beneficiary Overpayment Amount (WS-TR-OTH-BENE-OPA) for WS-TR-OTH-OPA-BIC
= A or WS-TR-OTH-BENE-OPA-BIC = B in the format $$$$$.¢¢
|
OPT133 – BENEFICIARY(S) DIE AND OVERPAYMENT RECOVERED FROM ANOTHER ENTITLED
BENEFICIARY
We paid you (1) more in benefits than we should have. The overpayment occurred because
we did not stop (2) benefits for (3). We can't pay benefits for the month of death,
(4), or later.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
New overpayment amount
|
Choice 2
|
If more than one dead beneficiary is overpaid and overpayments are being recovered
from another entitled beneficiary, then show the total amount of all overpaid beneficiaries
|
Fill-in (2)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) for
one overpaid beneficiary
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) plus
“and” for two overpaid beneficiaries followed by the Beneficiary’s Given Name (BGN)
plus Beneficiary’s Last Name (BLN) (possessive) for the second overpaid beneficiary
|
Choice 3
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) followed
by a comma followed by Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name
(BLN) (possessive) for the second overpaid beneficiary plus “and” followed by Beneficiary’s
Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive) for the third overpaid
beneficiary
NOTE: If more than three dead beneficiaries with the same BDOD and overpaid, then an Incomplete
notice will be generate (see Incomplete Notices under the Completion Code section
for the CODE and more information)
|
Fill-in (3)
|
|
Choice 1
|
Beneficiary's date of death when Beneficiary Date of Death (BDOD) = Current Operating
Month (COM) minus 1 month
|
Choice 2
|
Beneficiary's date of death plus “and” plus the Current Operating Month (COM) minus
1 month when the BDOD = COM minus 2 months
|
Choice 3
|
Beneficiary's date of death plus “through” plus COM minus 1 month when the Beneficiary
Date of Death (BDOD) > Current Operating Month (COM) minus 2 months
|
Fill-in (4)
|
Beneficiary Date of Death (BDOD)
|
OPT147 – DUE PROCESS TITLE II OVERPAYMENT RECOVERY LESS THAN FULL MONTHLY
BENEFIT AMOUNT
We will start recovering this overpayment by withholding 10 percent of the payment
(1) will receive on or about (2). The minimum we will withhold is $10. If the total
benefit is less than $10, we will withhold the entire benefit.
Fill-in values:
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|
Fill-in
(1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
|
Choice 2
|
you
|
Fill-in
(2)
|
Overpayment recovery date in Month DD, CCYY format
|
OPT148 – TITLE XVI (SSI) UNDERPAYMENT USED TO REDUCE OR RECOVERY A TITLE II
OVERPAYMENT (CROSS PROGRAM RECOVERY PHASE 3)
We used (1) of (2) SSI benefits to recover some or all of an overpayment on this record.
Fill-in values:
|
|
Fill-in (1)
|
Deductions Additions History Amount (DAH-AMOUNT) that corresponds to the Deductions
Additions History Type of Payment Code (DAH-TOP) = P and Deductions Additions History
Item Code (DAH-ITEM) = 382 in the format $$$$$$.¢¢
|
Fill-in (2)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
OPT149 – TITLE XVI (SSI) UNDERPAYMENT NOT USED TO REDUCE OR RECOVERY A TITLE II
OVERPAYMENT (CROSS PROGRAM RECOVERY PHASE 3)
We did not use any of (1) SSI benefits to recover an overpayment on this record.
Fill-in values:
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|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (possessive)
|
Choice 2
|
your
|
OPT216 – OVERPAYMENT CAUSED BY SUBSTANTIAL GAINFUL WORK ACTIVITY (SGA) DURING
THE EXTENDED PERIOD OF ELIGIBILITY (EPE) OR DISABILITY CESSATION DUE TO
SGA
(1) received (2) too much in benefits because of (3) work activity. Please read the
rest of this letter carefully. In it, we explain the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Choice 4
|
Number Holder’s Beneficiary Given Name (BGN) plus Beneficiary Last Name (BLN) (possessive)
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT217 – OVERPAYMENT ESTABLISHED VIA CROSS PROGRAM RECOVERY (CPR) TO RECOVER A
TITLE VIII SPECIAL VETERANS BENEFITS (SVB) PAID IN EXCESS
(1) received (2) too much in Special Veterans Benefit (SVB) payments. Please read
the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.
Fill-in values:
|
|
Fill-in (1) |
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2) |
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3) |
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT218 – OVERPAYMENT CAUSED DUE TO INCORRECT PAYMENTS FOR MEDICARE SERVICES
(1) received (2) too much in benefits because of incorrect payments for Medicare services.
Please read the rest of this letter carefully. In it, we explain the changes we made
to (3) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT219 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFCIARY WAS CONVICTED OF A CRIME
OR IMPRISONED FOR MORE THAN 30 DAYS DUE TO FELONIOUS HOMICIDE
(1) received (2) too much in benefits because (3) criminal conviction and imprisonment
for more than 30 days. Please read the rest of this letter carefully. In it, we explain
the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT220 – OVERPAYMENT CAUSED BY WINDFALL OFFSET
(1) received (2) too much in benefits because (3) received Supplemental Security Income
(SSI) payments (4) (5). Please read the rest of this letter carefully. In it, we explain
the changes we made to (6) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
from
|
Choice 2
|
in
|
Fill-in (5)
|
|
Choice 1
|
Month CCYY through Month CCYY
|
Choice 2
|
Month CCYY
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT221 – OVERPAYMENT ESTABLISHED BECAUSE MORE THAN ONE PAYMENT WAS CASHED FOR
THE SAME MONTH
(1) received (2) too much in benefits because we should not have paid two payments
for the same month(s). Please read the rest of this letter carefully. In it, we explain
the changes we made to (3) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT222 – OVERPAYMENT ESTABLISHED DUE TO INVALID FAMILY RELATIONSHIPS
(1) received (2) too much in benefits because (3) did not meet the relationship requirements
to receive benefits. Please read the rest of this letter carefully. In it, we explain
the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT223 – OVERPAYMENT ESTABLISHED BECAUSE OF INVALID ENTITLEMENT
(1) received (2) too much in benefits because (3) did not qualify for benefits. Please
read the rest of this letter carefully. In it, we explain the changes we made to (4)
benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT224 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WAS
DEPORTED
(1) received (2) too much in benefits because (3) deported from the United States.
Please read the rest of this letter carefully. In it, we explain the changes we made
to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you were
|
Choice 2
|
he was
|
Choice 3
|
she was
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT225 – OVERPAYMENT ESTABLISHED DUE TO INCORRECT COMPUTATION, A LEGALLY DEFINED
OVERPAYMENT OR TO RECOVER A SKELETON DUE PROCESS OVERPAYMENT
(1) received (2) too much in benefits because the payment amount was incorrect. We
corrected (3) record, which caused (4) benefit amount to decrease. Please read the
rest of this letter carefully. In it, we explain the changes we made to (5) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT226 – OVERPAYMENT ESTABLISHED DUE TO SUBVERSIVE ACTIVITY
(1) received (2) too much in benefits because (3) convicted of a crime against the
United States. Please read the rest of this letter carefully. In it, we explain the
changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you were
|
Choice 2
|
he was
|
Choice 3
|
she was
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT227 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY DID NOT HAVE A CHILD IN
THEIR CARE
(1) received (2) too much in benefits because (3) a child in (4) care who receives
benefits from us. Please read the rest of this letter carefully. In it, we explain
the changes we made to (5) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you no longer have
|
Choice 2
|
he no longer has
|
Choice 3
|
she no longer has
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT229 – OVERPAYMENT ESTABLISHED BECAUSE A WARRANT FOR THE BENEFICIARY’S ARREST
EXISTS
(1) received (2) too much in benefits. We should not have paid (3) because of a warrant
for (4) arrest. Please read the rest of this letter carefully. In it, we explain the
changes we made to (5) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
him
|
Choice 3
|
her
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT230 – OVERPAYMENT ESTABLISHED BECAUSE OF STATE OR FEDERAL ASSISTANCE
(1) received (2) too much in benefits because (3) received State or Federal assistance.
Please read the rest of this letter carefully. In it, we explain the changes we made
to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT231 – OVERPAYMENT CAUSED BY REPRESENTATIVE PAYEE MISUSE OF
BENEFITS
(1) received (2) too much in benefits because (3) misused funds while acting as a
representative payee. Please read the rest of this letter carefully. In it, we explain
the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT232 – OVERPAYMENT CAUSED BY DISABILITY CESSATION
(1) received (2) too much in benefits because we cannot pay benefits after (3) disability
ends. Please read the rest of this letter carefully. In it, we explain the changes
we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Choice 4
|
Number Holder’s Beneficiary Given Name (BGN) plus Beneficiary Last Name (BLN) (possessive)
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT234 – OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF PROVISIONAL BENEFITS ON A
CLAIM THAT WAS LATER DENIED
(1) received (2) too much in benefits because (3) you received temporary benefits
while we were making a decision on (4) claim that we later denied. Please read the
rest of this letter carefully. In it, we explain the changes we made to (5) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT235 – OVERPAYMENT ESTABLISHED DUE TO CROSS-BENEFIT ADJUSTMENT
We moved (1) overpayment of (2) to (3) for collection. Please read the rest of this
letter carefully. In it, we explain the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
another person's
|
Choice 2
|
Number Holder’s Beneficiary Given Name (BGN) plus Beneficiary Last Name (BLN) (possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN)
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT236 – OVERPAYMENT ESTABLISHED DUE TO CHANGE IN THE AMOUNT OR COMMENCEMENT OF
THE GOVERNMENT PENSION OFFSET
(1) received (2) too much in benefits because we must offset (3) benefit payments
due to (4) receipt of a government pension. Please read the rest of this letter carefully.
In it, we explain the changes we made to (5) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT237 – OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF A PENSION BASED ON WORK NOT
COVERED BY SOCIAL SECURITY TAXES
(1) received (2) too much in benefits because (3) received a pension based on work
not covered by Social Security taxes. Please read the rest of this letter carefully.
In it, we explain the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Choice 4
|
Wage Earner’s Name
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT238 – OVERPAYMENT ESTABLISHED DUE TO RECEIPT OF PAYMENTS AFTER CONFINEMENT TO
A MENTAL INSTITUTION BECAUSE OF A COURT ORDER
(1) received (2) too much in benefits because (3) received payments after being confined
to an institution because of a court order. Please read the rest of this letter carefully.
In it, we explain the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT239 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WAS AN ALIEN LIVING
OUTSIDE THE UNITED STATES WHILE RECEIVING BENEFITS
(1) received (2) too much in benefits because (3) not a United States citizen and
(4) outside the country for six months in a row. Please read the rest of this letter
carefully. In it, we explain the changes we made to (5) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you are
|
Choice 2
|
he is
|
Choice 3
|
she is
|
Fill-in (4)
|
|
Choice 1
|
you were
|
Choice 2
|
he was
|
Choice 3
|
she was
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT240 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY WORKED OUTSIDE THE US
IN A JOB NOT COVERED UNDER SOCIAL SECURITY TAXES
(1) received (2) too much in benefits because (3) worked outside the United States
in a job not covered by United States Social Security taxes. Please read the rest
of this letter carefully. In it, we explain the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT241 – OVERPAYMENT ESTABLISHED DUE TO PRISONER SUSPENSION
(1) received (2) too much in benefits because of (3) criminal conviction and confinement
in a correctional institution for more than 30 days. Please read the rest of this
letter carefully. In it, we explain the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT242 – OVERPAYMENT ESTABLISHED DUE TO DEATH RECLAMATION, REPRESENTATIVE PAYEE
ELECTRONIC FUNDS TRANSFER (EFT) AFTER DEATH OR REPRESENTATIVE PAYEE DEATH
(1) received (2) too much in benefits because we cannot pay benefits for the month
of death or later. Please read the rest of this letter carefully. In it, we explain
the changes we made to (3) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT243 – OVERPAYMENT ESTABLISHED DUE TO PERMANENT DEDUCTIONS RESULTING FROM THE
ANNUAL EARNINGS TEST
(1) received (2) too much in benefits because of (3) work and earnings. Please read
the rest of this letter carefully. In it, we explain the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Choice 4
|
Null
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT244 – OVERPAYMENT ESTABLISHED DUE TO DEATH SUPER-ENDORSEMENT
(1) received (2) too much in benefits because (3) signed and cashed a check for the
month of death or later . Please read the rest of this letter carefully. In it, we
explain the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT245 – OVERPAYMENT ESTABLISHED DUE TO A CHANGE IN MARITAL STATUS
(1) received (2) too much in benefits because of a change in (3) marital status. Please
read the rest of this letter carefully. In it, we explain the changes we made to (4)
benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT246 – OVERPAYMENT ESTABLISHED DUE TO ENTITLEMENT TO WORKERS’ COMPENSATION,
PUBLIC DISABILITY OR BOTH
(1) received (2) too much in benefits because of (3) receipt of workers’ compensation,
public disability payments or both of these payments. Please read the rest of this
letter carefully. In it, we explain the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT247 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY CONTINUED TO RECEIVE
BENEFITS AFTER THE AGE OF 18
(1) received (2) too much in benefits because we do not pay benefits once a student
reaches age 18, unless he or she is a full time student elementary or high school
student. Please read the rest of this letter carefully. In it, we explain the changes
we made to (3) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT248 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY CONTINUED TO RECEIVE
BENEFITS AFTER AGE 19 OR 22
(1) received (2) too much in benefits because we do not pay benefits once a full-time
student reaches age 19, unless (3) disabled or meet(s) an exception which allows benefits
to continue:
-
•
for 2 months after a student turns 19, or;
-
•
until the end of the school term, whichever comes first.
Please read the rest of this letter carefully. In it, we explain the changes we made
to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you are
|
Choice 2
|
he is
|
Choice 3
|
she is
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT249 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY IS NO LONGER IN
FULL-TIME SCHOOL ATTENDANCE
(1) received (2) too much in benefits because we do not pay benefits once a student
stops going to school full-time. Please read the rest of this letter carefully. In
it, we explain the changes we made to (3) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT250 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICIARY REFUSED TO ACCEPT
VOCATIONAL REHABILITATION
(1) received (2) too much in benefits because we should not have paid benefits when
(3) refused vocational rehabilitation services. Please read the rest of this letter
carefully. In it, we explain the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT252 – OVERPAYMENT ESTABLISHED DUE TO UNPAID ATTORNEY FEES
(1) received (2) too much in benefits because of unpaid attorney’s fees. Please read
the rest of this letter carefully. In it, we explain the changes we made to (3) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT253 – OVERPAYMENT ESTABLISHED RAILROAD RETIREMENT BOARD EARNINGS WERE
INCORRECTLY USED TO ESTABLISH THE BENEFICARY’S ENTITLEMENT
(1) received (2) too much in benefits because (3) received incorrect payments from
the Railroad Retirement Board. Please read the rest of this letter carefully. In it,
we explain the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT254 – OVERPAYMENT ESTABLISHED BECAUSE THE BENEFICARY WAS NOT A UNITED STATES
(U.S.) CITIZEN OR LAWFULLY PRESENT IN THE U.S.
(1) received (2) too much in benefits because (3) received payments even though (4)
not a United States citizen or lawfully present in the U.S. Please read the rest of
this letter carefully. In it, we explain the changes we made to (5) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
you were
|
Choice 2
|
he was
|
Choice 3
|
she was
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT255 – OVERPAYMENT ESTABLISHED BECAUSE THE MONTH OF ENTITLEMENT WAS
INCORRECT
(1) received (2) too much in benefits because of a change in the month (3) benefits
started. Please read the rest of this letter carefully. In it, we explain the changes
we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT257 – OVERPAYMENT ESTABLISHED DUE TO MULTIPLE ENTITLEMENTS
(1) received (2) too much in benefits because (3) received payments on two or more
records for the same month(s). Please read the rest of this letter carefully. In it,
we explain the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2) |
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT258 – OVERPAYMENT ESTABLISHED BECAUSE INSURED STATUS WAS NOT
MET
(1) received (2) too much in benefits because (3) worked long enough under Social
Security to receive monthly benefits. Please read the rest of this letter carefully.
In it, we explain the changes we made to (4) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you have not
|
Choice 2
|
he has not
|
Choice 3
|
she has not
|
Fill-in (4)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT259 – OVERPAYMENT ESTABLISHED BECAUSE THE BENFICIARY MISUSED FUNDS WHILE
SERVING AS A REPRESENTATIVE PAYEE
(1) received (2) too much in benefits because (3) misused benefits that (4) received
as the representative payee for another person. Please read the rest of this letter
carefully. In it, we explain the changes we made to (5) benefits.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
You
|
Choice 2
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Fill-in (2)
|
Overpayment amount in the format $$$$$.¢¢
|
Fill-in (3)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (4)
|
|
Choice 1
|
you
|
Choice 2
|
he
|
Choice 3
|
she
|
Fill-in (5)
|
|
Choice 1
|
your
|
Choice 2
|
his
|
Choice 3
|
her
|
OPT302 – OVERPAYMENT TRANSFERRED FROM ANOTHER RECORD FOR A DUALLY
ENTITLED BENEFICIARY
We have determined that (1) (2) overpaid (3) on another record. We will recover this
overpayment on this record.
Fill-in values:
|
|
Fill-in (1)
|
|
Choice 1
|
Beneficiary’s Given Name (BGN) plus Beneficiary’s Last Name (BLN) (not possessive)
|
Choice 2
|
you
|
Fill-in (2)
|
|
Choice 1
|
is
|
Choice 2
|
are
|
Fill-in (3)
|
Overpayment amount in the format $$$$$.¢¢
|