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This change was made on Jul 12, 2018. See latest version.
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NL 00703.700: Withdrawal — Repayment — NH

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  • Effective Dates: 07/18/2014 - Present
  • Effective Dates: 07/12/2018 - Present
  • TN 30 (03-96)
  • TN 74 (07-18)
  • NL 00703.700 Withdrawal — Repayment — NH
  • Document Identifier for Word Processor: E3700
  • Document Identifier for Aurora: E3700
  • A. Exhibit letter
  • If we approve your request for withdrawal of your application for (1) benefits, it would have the effect of completely cancelling your previous claim. All payments which you received based on the previous claim must be repaid before we can approve your request for withdrawal.
  • You became entitled to monthly benefits of $ (2) beginning (3) . The last monthly payment you received was for (4) . This means that you received a total of $ (5) which you must repay.
  • E3700.1 (Required)
  • If we approve (#1) request to withdraw (#2) claim for (#3), we will completely cancel the claim.
  • We can approve the withdrawal only if (#4) all the money paid from the claim. This includes any money we withheld from (#5) benefits.
  • If (#6) withdrawal request includes Medicare, (#7) must repay any costs for Medicare Part A (Hospital Insurance) services (#8) received.
  • What (#9) must repay
  • (#10) $ (#11)
  • (#12)
  • (#13)
  • E3700.1A
  • (Optional)
  • 3700A
  • However, you will not have to send us this entire amount. If we approve your withdrawal, you will become entitled to (1) benefits based on your new application. Your new claim will be effective (2) at the rate of $ (3) . We will use $ (4) benefits accrued on your claim to reduce the amount you must repay.
  • $ (#1) (#2)
  • If you wish to withdraw your claim, send a certified check or money order for $ (6) , made payable to the Social Security Administration. Mail your payment to us using the enclosed refund envelope. Please do not mail your payment to the address at the top of this notice. Be sure to write the Social Security claim number listed at the top of this notice on the check or money order.
  • E3700.1B
  • 3700B
  • If you decide that you do not want to withdraw your claim, or if you have any questions, call us toll-free at 1-800-772-1213, or call your local Social Security office at (FO telephone number).
  • (Required)
  • (#14) $ (#15)
  • This means (#16) must repay us a total of $ (#17) before we can withdraw the claim.
  • E3700A (Optional)
  • However, you will not have to send us this entire amount. If we approve your withdrawal, you will become entitled to (#1) benefits based on your new application. Your new claim will be effective (#2) at the rate of $ (#3). We will use $ (#4) benefits accrued on your claim to reduce the amount you must repay.
  • E3700.2
  • (Required)
  • If you wish to withdraw (#1) claim, (#2) must send us a check or money order for $ (#3). Make the check or money order payable to the Social Security Administration. Be sure to write the Social Security Claim Number on (#4) payment.
  • Please mail (#5) payment to us using the enclosed refund envelope. Do not mail (#6) payment to the address at the top of this notice.
  • E3700B
  • (Required)
  • If you decide that you do not want to withdraw your claim, or if you have any questions, call us toll-free at 1-800-772-1213, or call your local Social Security office at 1-(#3)(#4)(#5).
  •  
  • We can answer most questions over the phone. You can also write or visit any Social Security office. The office that serves your area is located at:
  •  
  • (#6)
  • (#7)
  • District Office Address City, ST ZIP
  • (#8)
  •  
  • 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.
  • (#9) (#10)-(#11)
  •  
  • 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.
  • Enclosure:
  • Refund envelope
  • B. Requesting instructions
  • * The request for this letter may be made on Form SSA-573 or SSA-559 by the claims authorizer or by the benefit authorizer. The authorizer will furnish the fill-in information and, if necessary, any additional paragraphs that may be needed.
  • * Use 3700A when a new claim is filed with the withdrawal request and benefits will be paid.
  • * Use 3700B in all cases.
  • * Use E3700A only when a new claim is filed with the withdrawal request and benefits will be paid.
  • * Use E3700.1, E3700B, and E3700.2 in all cases.
  •  
  • Fill-ins:
  • * Type of benefits, e.g. “retirement” or “disability”
  • * Amount of monthly benefits
  • * Month/Year monthly benefits began
  • * Month/Year of last monthly payment
  • * Amount of benefits received
  • * Amount of benefits that must be repaid
  • Paragraph 3700A:
  • * Type of benefits, e.g. “retirement” or “disability”
  • * Month/Year benefits will be effective
  • * Amount of monthly payment
  • * Amount of benefits accrued
  • C. Fill-ins:
  • E3700.1
  • * your/Requestor’s Full Name (possessive)
  • * your/his/her/Beneficiary’s Full Name (possessive)
  • * A = retirement benefitsB = disability benefitsC = survivor’s benefitsD = retirement benefits and MedicareE = disability benefits and MedicareF = survivor’s benefits and MedicareG = Medicare
  • * you repay/he repays/she repays
  • * your/his/her
  • * your/his/her
  • * you/he/she
  • * you/he/she
  • * you/he/she
  • * A = nullB = The cost of the Medicare Part A services you received isC = The cost of the Medicare Part A services he received isD = The cost of the Medicare Part A services she received is
  • * Null/Amount
  • * A = null (if repayment is for Medicare only)B = You received, or will receive, Social Security benefits of:C = He received, or will receive, Social Security benefits of:D = She received, or will receive, Social Security benefits of:
  • * A = null (If repayment is for Medicare only)B = (Activate UTI E3700.1A Chart UTI)
  • E3700.1A
  • * Benefit amount
  • * Benefit month A/B, MM/YYYY, MM/YYYYA = MM/YYYYB = MM/YYYY through MM/YYYY
  • * Another Line? (Y/N)/NULL
  • E3700.1B
  • * A = NULLB = Amount already returned
  • * Amount refunded or NULL
  • * you/he/she
  • * Total amount to be repaid
  • E3700A
  • * Type of benefits, e.g. “retirement” or “disability”
  • * Month/Year benefits will be effective (MM/YYYY)
  • * Amount of monthly payment
  • * Amount of benefits accrued
  • E3700.2
  • * your/Name (possessive)
  • * you/he/she
  • * Total amount to be repaid
  • * your/his/her
  • * your/his/her
  • * your/his/her
  • E3700B
  • * Addressee zip code (5 digits)
  • * Addressee zip+4 (4 digits)
  • * Telephone area code (3 digit)
  • * Phone exchange (3 digit)
  • * Phone number (4 digit)
  • * Local office address line 1
  • * Local office address line 2
  • * Local office address line 3
  • * Local office city and state
  • * Local office zip code (5 digits)
  • * Zip+4 of local office (4 digits)
  • C. Typing instructions
  • D. Typing instructions
  • Use Form SSA-L2000-C2. The typist should enclose a self-addressed envelope with the notice and the claim number should be written on the inside of the envelope below the flap.
The materials available at this web site are provided free of charge, for informational purposes only, and without warrant by True Link Financial, Inc., and are not legal advice or Social Security benefits advice. You should contact your attorney to obtain advice with respect to any particular issue or problem, or the Social Security Administration with any general inquiries. Click here to view this section of the POMS on the Social Security Administration website.