TN 17 (02-93)

SOCIAL SECURITY ADMINISTRATION
MID-ATLANTIC PROGRAM SERVICE CENTER
PHILADELPHIA, PENNSYLVANIA 19123

CERTIFICATE OF INDEBTEDNESS

Claim No. XXX-XX-XXXXB2

Total debt due United States as of  (Date) :  $               

I certify that the Social Security Administration records show that the debtor(s) named above is/are indebted to the United States in the amount stated above.

The claim arose in connection with an overpayment of Social Security benefits.

Section 203(c) of the Social Security Act provides that an individual entitled to a mother's insurance benefit for any month, shall suffer a deduction equal to the full amount of such benefit, if in a given month she did not have in her care a child entitled to a child's insurance benefit under age 16 or under a disability which began before the child attained age 16.

From     through     the debtor named above did not have an entitled child in her care and was, therefore, not due any benefit payments. She was, in fact, paid benefits
totaling    , of which     has been adjusted, pursuant to Section 204(a) of the Social Security Act, leaving an unsatisfied indebtedness of    . (1)

CERTIFICATION: Pursuant to 28 USC section 1746, I certify under penalty of perjury that the foregoing is true and correct.

  (Signature or ARC PCO or Director, ODIO   

  (Type Name of ARC, PCO or Director, ODIO

  (Title)                                  

  Date             (2)              

1. If the debtor has made a partial refund of the overpayment, amend this sentence to "... has been repaid, leaving an unsatisfied indebtedness of."

2. The date should be written in ink when the ARC, PCO signature is affixed.