Social Security Administration
Retirement, Survivors, and Disability
Insurance
Important Information
Mid-Atlantic Program Service Center
225 E. Oak
Street
Central
City, ST 00000
Date: July
1, 2005
Claim Number:
XXX-XX-6789A
Jane Doe
6401 Security Blvd.
Baltimore, MD 21235-6401
We cannot pay benefits to you for the months of 01/2005 to 03/2005 because you had
an outstanding arrest warrant for a crime which is a felony.
Information About Your Benefits
Beginning January 2005, the law prohibits us from paying Social Security benefits
to individuals who have an outstanding arrest warrant for a crime which is a felony
(or, in jurisdictions that do not define crimes as felonies, a crime that is punishable
by death or imprisonment for a term exceeding 1 year), or who have violated a condition
of probation or parole under Federal or State law. We have information that you fall
into one of these categories.
The Information We Have
Our records show that the XYZ Sheriffs Dept., 123 Cypress Lane, Baltimore, MD 12345,
PHONE: 800-923-4567, issued a warrant for your arrest for a felony crime or a violent
of Federal or State probation or parole on 1/12/2005.
The warrant information we have is:
Warrant number: MD123456
Originating case number: 2345678
National Crime Information Center number: 3456789
Social Security cannot provide further information about the warrant. Please contact
the XYZ Sheriffs Dept. directly.
How You Can Avoid Being Overpaid
You will not be overpaid for the months that you had an outstanding felony warrant
for a crime or a warrant for a probation or parole violation if you contact us at any time and can
show us that any of the following apply:
-
•
The warrant was issued incorrectly in your name because someone stole your identity.
To prove this, submit a copy of the police report that you filed as a victim of identity
theft or another official document from the court or the warrant issuing agency stating
that the warrant was erroneously issued in your name.
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•
You were found not guilty of the criminal offense. To prove this, submit a copy of
the court docket indicating you were found not guilty of the criminal charges or a
copy of the court decision showing that you were found not guilty of the criminal
charges.
-
•
The underlying charges relating to the criminal offense were dismissed. To prove this,
submit a copy of the court docket indicating charges were dismissed or another official
court or law enforcement agency document stating that it dismissed the criminal charges.
-
•
The warrant for your arrest for the criminal offense was withdrawn. To prove this,
submit a copy of the court docket or another official document from the issuing agency,
indicating the warrant in question was withdrawn.
-
•
You were otherwise cleared of the criminal offense. To prove this, submit a copy of
the court docket or other court document indicating you were cleared of the criminal
charges.
If none of the above applies, we also may not consider you overpaid for the months
of 01/2005 to 03/2005 if you contact us within 12 months from the date of this letter
and can show us that:
-
•
The crime for which the warrant was issued or the probation or parole violation was
both nonviolent and not drug related and, if a probation or parole violation is involved,
the original crime(s) for which you were paroled or put on probation was both nonviolent
and not drug related.
And
-
•
You have neither been convicted of nor pled guilty to another felony crime since the
date of the warrant.
And
-
•
The law enforcement agency that issued the warrant reports that it will not extradite
you for the charges on the warrant or that it will not take action on the warrant
for your arrest.
Or
-
•
The crime for which the warrant was issued is based on or the probation or parole
violation was both nonviolent and not drug related and, if a probation or parole violation
is involved, the original crime(s) for which you were paroled or put on probation
was both nonviolent and not drug related.
And
-
•
You have neither been convicted of nor pled guilty to another felony crime since the
date of the warrant.
And
-
•
The only existing warrant was issued 10 or more years ago.
And
Your medical condition impairs your mental capability to resolve the warrant; or you
are incapable of managing your benefits; or you are legally incompetent; or Social
Security has appointed a representative payee to handle your benefits or you are residing
in a long-term care facility, such as a nursing home or mental treatment/care facility.
Overpayment Information
We cannot pay benefits to you for the months of 01/2005 to 03/2005 because you had
an outstanding arrest warrant
Since we did not stop your payments for the period 01/2005 to 03/2005, you were paid
$1,500 too much in benefits.
Do You Think We Are Wrong About The Overpayment?
You have certain rights with respect to this overpayment and its recovery.
-
1.
Right to Appeal: If you disagree in any way with this overpayment determination, you have the right,
within 60 days of the date you receive this notice, to request that the determination
be reconsidered. If you request this independent review of the overpayment determination,
please submit any additional information you have which pertains to the overpayment.
-
2.
Right to Request Waiver: You also have the right to request a determination concerning the need to recover
the overpayment. An overpayment must be refunded or withheld from benefits unless
both of the following are true:
-
a.
The overpayment was not your fault in any way; and
-
b.
You could not meet your necessary living expenses if we recovered the overpayment,
or recovery would be unfair for some other reason.
If you request waiver, we may need a statement of your assets and monthly income and
expenses.
If you request reconsideration and/or waiver within 30 days, the overpayment will
not have to be recovered until the case is reviewed. This review is described in more
detail on the attached Form SSA-3105, Important Information About Your Appeal and
Waiver Rights. The people in any Social Security office will be glad to help you complete
the forms for requesting reconsideration (SSA-561-U2, Request for Reconsideration)
and/or waiver (SSA-632-F4, Overpayment Recovery Questionnaire).
Even if you do not want to request reconsideration or waiver, please call, write or
visit any Social Security office if you have any questions or need more information.
Please take this letter with you if you do visit an office.
How To Pay Us Back
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 your claim number (as indicated above) on the check or money order.
If you cannot refund the full $1,500 now, you should submit: (a) a partial payment;
(b) an explanation of your financial circumstances; and (c) a definite plan for repaying
the balance.
If we do not receive your refund within 30 days, we plan to recover the overpayment
by withholding your full benefit beginning with the payment you would normally receive
for August 2005 about September 1, 2005. We will continue withholding the benefit
you receive until the overpayment has been fully recovered.
If You Disagree With The Decision
If you disagree with this decision, you have the right to appeal. We will review your
case and consider any new facts you have. A person who did not make the first decision
will decide your case. We will correct any mistakes. We will review those parts of
the decision which you believe are wrong and will look at any new facts you have.
We may also review those parts which you believe are correct and may make them unfavorable
or less favorable to you.
-
•
You have 60 days to ask for an appeal.
-
•
The 60 days start the day after you get this letter. We assume you got this letter
5 days after the date on it unless you show us that you did not get it within the
5-day period.
-
•
You must have a good reason for waiting more than 60 days to ask for an appeal.
-
•
You have to ask for an appeal in writing. We will ask you to sign a Form SSA-561-U2,
called "Request for Reconsideration." Contact one of our offices if you want help.
Please read the enclosed pamphlet, "Your Right to Question the Decision Made on Your
Social Security Claim." It contains more information about the appeal.
If You Want Help With Your Appeal
You can have a friend, representative, or someone else help you. There are groups
that can help you find a representative or give you free legal services if you qualify.
There are also representatives who do not charge unless you win your appeal. Your
Social Security office has a list of groups that can help you with your appeal. If
you get someone to help you, you should let us know. If you hire someone, we must
approve the fee before they can collect it.
Enclosure:
SSA-3105
Refund Envelope
NOTE: The referral paragraph and the appropriate signature are also required for this notice.
See NL 00601.040 for additional paragraphs required on post-entitlement notices; e.g., Medicare paragraphs,
etc. See NL 00601.003 for name and signature requirements on notices.