TN 65 (03-15)

Document Identifier for Aurora: E3102

DPS Notices: Notice to Overpaid Person in Pay/Nonpay — Title 2

Notice of Overpayment (Rep Payee) — SSA-L8165

A. Exhibit Letter

You received *F1 more in *F2 benefits *F3 than *F4 due. *F5 (OPT188)

How To Pay Us Back

Please refund this overpayment within 30 days. Make your check or money order payable to "Social Security Administration" and send it to us in the enclosed envelope. Include *F1 claim number shown above on the check or money order. If you cannot refund the full *F2 now, please submit: (a) a partial payment; (b) an explanation of your financial situation; and (c) a definite plan to repay the balance.

If we do not receive your refund within 30 days, we plan to recover the overpayment by withholding *F3 full benefit beginning with the payment you would normally receive for *F4 about *F5. We will continue to withhold the benefit you receive for *F6 until the overpayment has been fully recovered. (3102A)

Or

To recover the overpayment, we will withhold the payment you would normally receive *F1 about *F2. You will receive *F3 monthly payment again about *F4. (3104B)

Or

We plan to recover the overpayment from the payment you would normally receive for *F1 about *F2. The reduced payment will be $*F3 and you will receive the regular monthly payment about *F4. (3102B)

If You Think You Should Not Have To Pay Us Back

You may not have to pay us back. Sometimes we can waive the collection of an overpayment, which means you will not have to pay us back. For us to waive the collection of your overpayment, two things must be true.

• It was not your fault that you got too much Social Security money.

  • AND

Paying us back would mean you cannot pay your bills for food, clothing, housing, medical care, or other necessary expenses, or it would be unfair for some other reason.

If you think these are true about you, contact any Social Security office¹. You can ask for waiver at any time by filling out the waiver form. The form number is SSA-632-BK. We will not collect the overpayment while we decide if we can waive collection. If you ask for waiver in the next 30 days, we will not withhold benefits until we decide if we can waive collection.

You may need to show us proof of your monthly income, expenses, and assets. Examples are pay stubs, pension records, rent receipts, utility bills and bank statements. (3100C)

If You Disagree With The Decision

If you disagree with the decision, you have the right to appeal. A person who did not make the first decision will decide your case. We will review your case again and consider any new facts you have.

• You have 60 days to ask for an appeal. If you ask in the next 30 days, you will not have to pay us back until we decide your case.

• Both the 30- and 60-day periods start the day after you receive 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 if you wait 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 called “Request for Reconsideration.” The form number is SSA-561-U2. To get this form, contact one of our offices. We can help you fill out the form.

We are enclosing a pamphlet called “Important Information About Your Appeal and Waiver Rights.” Please be sure to read it.

Even if you do not want to request reconsideration or waiver, call us at 1-800-772-1213 if withholding of the monthly payment will cause hardship. Unless we hear from you within 30 days, we will withhold the benefit as shown above. (3100D Domestic)

Or

If you disagree with the decision, you have the right to appeal. A person who did not make the first decision will decide your case. We will review your case again and consider any new facts you have.

• You have 60 days to ask for an appeal. If you ask in the next 30 days, you will not have to pay us back until we decide your case.

• Both the 30- and 60-day periods start the day after you receive this letter.

• You must have a good reason if you wait more than 60 days to ask for an appeal.

• You have to ask for an appeal in writing.

We are enclosing a pamphlet called “Important Information About Your Appeal and Waiver Rights.” Please be sure to read it.

Even if you do not want to request reconsideration or waiver, please call, write or visit *F1-1 if withholding of the monthly payment will cause hardship. Please take this letter with you if you do visit an office. Unless we hear from you within 30 days, we will withhold the benefit as shown above. (3100F Foreign)

If You Want Help With Your Appeal¹ (REPC01)

You may choose to have a representative help you. We will work with this person just as we would work with you. If you decide to have a representative, you should find one quickly so that person can start preparing your case.

Many representatives charge a fee only if you receive benefits. Others may represent you for free. Usually, your representative may not charge a fee unless we approve it. Your local Social Security office can give you a list of groups that can help you find a representative.

If you get a representative, you or that person must notify us in writing. You may use our Form SSA-1696 "Appointment of Representative." Any local Social Security office can give you this form. (REP002)

If You Have Any Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any questions, you should contact *F1. You may also write to the Social Security Administration, P.O. Box 17769 Baltimore, Maryland 21235, U.S.A. Please be sure to include your claim number if you do write. However, if you visit an office, please take this letter. It will help the people there answer your questions. (3901D Foreign)

Or

Suspect Social Security Fraud?

Please visit Office of the Inspector General or call the Inspector General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).

If You Have Any Questions

We invite you to visit our website at www.socialsecurity.gov on the Internet to find general information about Social Security. If you have any specific questions, you may call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-*F3- *F4- *F5. We can answer most questions over the phone. If you are deaf or hard of hearing, you may call our TTY number, 1-800-325-0778. You can also write or visit any Social Security office. The office that serves your area is located at:

*F6
*F7
*F8
*F9 *F10- *F11

If you do call or visit an office, please have this letter with you. It will help us answer your questions. Also, if you plan to visit an office, you may call ahead to make an appointment. This will help us serve you more quickly when you arrive at the office. (CTDO Domestic)

Enclosure(s):

Refund envelope²

SSA-3105

¹ If the person lives outside of the U.S. or has an attorney, omit this paragraph.

² If overpayment is less than the monthly payment, omit refund envelope.

B. Requesting Instructions

The person who determines the overpayment (generally the benefit authorizer) is responsible for requesting this notice and providing the appropriate fill-ins.

If the overpayment computation is too complex for a simple narrative explanation, use a chart such as the following:

OPT188 Fill-Ins:

*F1-1 Amount of overpayment
*F2-1 Social Security
*F2-2 Black Lung
*F3-1 for (Name of beneficiary)
*F3-2 leave blank
*F4-1 he was
*F4-2 she was
*F4-3 you were
*F5-1 explanation of overpayment

You must select one of the following UTIs:

• Use 3102A if the overpayment exceeds the monthly payment.

• Use 3104B if the overpayment equals the monthly payment.

• Use 3102B if the overpayment is less than the monthly payment.

3102A Fill-Ins:

*F1–1 your
*F1–2 his
*F1–3 her
*F2-1 amount of overpayment
*F3-1 Beneficiary's Name
*F4-1 him
*F4-2 her
*F5-1 Date
*F6-1 Beneficiary's Name
*F6-2 him
*F6-3 her

3102B Fill-Ins:

*F1-1 Name(s) of beneficiary
*F2-1 MM/DD/YYYY payment will be received
*F3-1 Amount of payment
*F4-1 MM/DD/YYYY payment will be received

3104B Fill-Ins:

*F1-1 for him
*F1-2 for her
*F1-3 leave blank
*F2-1 Month DD, YYYY
*F3-1 your
*F3-
*F3-3 her
*F4-1 Month DD, YYYY

You must select one of the following UTIs: 

• Use 3100D if the beneficiary lives in the U.S.

• Use 3100F if the beneficiary lives outside the Unites States.

3100F Fill-Ins:

*F1-1 Use a fill-in from paragraph 3901D in NL 00703.005E

CTDO (Domestic) Fill-Ins:

*F1-1 Zip code
*F2-1 Zip+4
*F2-2 DO Code
*F3-1 Telephone Area Code
*F4-1 Phone Exchange
*F5-1 Phone Number
*F6-1 Local Office Address Line #1
*F7-1 Local Office Address Line #2
*F8-1 Local Office Address Line #3
*F9-1 City & State of Local Office
*F10-1 Local Office Zip code
*F11-1 Zip+4 of Local Office