Basic (07-03)

NL 00740.060 Low Remittance - Did You Forget?


A "Low Remittance - Did You Forget?" bill is the first reminder sent when a debtor makes a partial payment for a prior month(s) and is currently behind in his/her agreed payments.


A "Low Remittance - Did You Forget?" bill generates when the debtor is behind in his/her agreed payments by at least one, but less than two, times the amount in the installment agreement. The amount due on this bill will be the current installment amount plus the balance of the prior installment amounts.


Social Security Administration

Billing Statement

Important Information


Susan A Patrick

1234 5th Avenue

Huntington NY 10101

(Bar Code goes here)



STATEMENT DATE:       09/05/02


ACCOUNT NUMBER:     12345678901


AMOUNT DUE:                $65.00



BALANCE FROM PREVIOUS STATEMENT                             $325.00


PAYMENT RECEIVED - 08/12/02 - THANK YOU                      $5.00


NEW BALANCE                                                                           $320.00



MUST REACH US BY:                                                                 09/23/02




This statement concerns an overpayment of Social Security benefits paid in error to SUSAN PATRICK, C1; JOE A PATRICK, C2; JOHN A PATRICK, C3; and FRED PATRICK, C4.

We did not receive the full payment of $40.00 which was due by 08/23/02. Please send us the amount shown below, which reflects this month's payment plus the remainder from last month's amount due.



Refund Env.


                                                           See Next Page



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To request to repay a smaller amount monthly over a longer period of time, please call us at the telephone number below.

If you have mailed the past due amount of $35.00 within the past week, you should only make this month's payment of $30.00.

If you have any questions, you may call us at 718-557-6600 (LOCAL CALL). The office hours are Monday through Friday, 8:00 AM TO 5:45 PM ET. Please have this statement available when you call.


If you call us using a TDD machine, please pause after you type a few words. This will give us time to transfer your call to the TDD line.



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                                                                                      OMB No 0960-0462


                                       PAYMENT STUB


  • Return the bottom portion of the stub with your payment.

  • Use the enclosed envelope to mail your payment to us; make sure our address shows through the window of the envelope.

  • Do not send cash.

  • Do not enclose any correspondence with your remittance. Send any correspondence to: Social Security Administration, Northeastern Program Service Center, PO Box 314400, Jamaica, NY 11431-9887

  • If you have changed your address or telephone number, be sure to check the box below and write your new address or telephone number in the space provided.

  • If you pay by check or money order, include the Social Security Account Number as shown below and make the check or money order payable to "Social Security Administration."

  • If paying by credit card, complete the appropriate information below and return it in the enclosed envelope


    to pay by phone, call 718-557-6600 (LOCAL CALL), during the hours 8:00 AM TO 5:45 PM ET. Please have this notice and your credit card available when you call.


SSA-53-EP                         DETACH HERE. DO NOT STAPLE.





Credit Card Number

Exp Date






September 23, 2002










Cardholder's Signature






Check box if your address or

[] telephone number has changed.

Make changes below.





PO BOX 3430



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        Privacy Act and Paperwork Reduction Act Statements


The Social Security Administration (SSA) has authority to collect the information requested on the PAYMENT STUB under section 204 of the Social Security Act. Giving us this information is voluntary. You do not have to do it. We will need this information only if you choose to make payment by credit card. You do not need to fill out the credit card information if you choose another means of payment (for example, by check or money order).

If you choose the credit card payment option, we will provide the information you give us to the banks handling your credit card account and SSA’s account. This will allow you to repay your overpayment with your credit card. We may also provide this information to another person or government agency to comply with federal laws requiring the release of information from our records. You can find these and other routine uses of information provided to SSA listed in the Federal Register. If you want more information about this, you may call or write any Social Security office.

We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.

Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.

This information collection meets the clearance requirements of 44 U.S.C. section 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions unless we display a valid Office of Management Budget control number. We estimate that it will take you about 6 minutes to read the instructions, gather the necessary facts, and answer the questions.

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NL 00740.060 - Low Remittance - Did You Forget? - 07/09/2003
Batch run: 03/29/2017