BASIC (04-14)

A. When to use notice

Use this notice to follow up when the beneficiary or recipient has an agreement to repay and is no longer entitled to monthly benefits. The notice is available in the Document Processing System.

B. Follow up notice when the beneficiary or recipient is no longer entitled to Title II and Title XVI benefits and has an agreement to repay for

We are writing to you about your agreement to repay us [1] for [2] [3] checks you cashed after [4] death.

Your Agreement

You agreed to repay the money because you cashed those checks. You asked us to hold back [5] from your [6] payment each month until the [7] is paid back.

What You Should Do

Since you are no longer entitled to monthly [8] benefits, you are personally liable for repayment of the [9]. We have written to you about this before, but you have not settled this matter. You should repay this money now, or contact us about how you will pay us back.

If We Do Not Hear From You

If you do not pay us or get in touch with us about this matter by [10], we will consider sending this case to the Office of the Inspector General or the United States Secret Service for prosecution.

If You Have Any Questions

If you have any questions, you may call us at 1-800-772-1213, or call your local Social Security office at [11]. We can answer most questions over the phone. You may also write or visit any Social Security office. The office that serves your area is located at: [12]

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

C. Completed follow up notice when the beneficiary or recipient is no longer entitled to Title II or Title XVI benefits and has an agreement to repay

Social Security Administration
Retirement, Survivors and Disability Insurance
Important Information

Miscellaneous Program Service Center
600 West Madison Street
Chicago, IL 60661-2474

Date:

Claim Number: 123-00-6789A

Mrs. Jane Doe
103 Main Street
Washington, DC 20019

If you do not pay us or get in touch with us about this matter by XX/XX/XX, we will consider sending this case to the Department of Justice.

We are writing to you about your agreement to repay us $500 for John Doe's Social Security checks you cashed after his death.

Your Agreement

You agreed to repay the money because you cashed those checks. You asked us to hold back $100 from your Social Security benefit check each month until you have repaid the $500.

What You Should Do

Since you are no longer entitled to monthly Social Security benefits, you are personally liable for repayment of the $500. We have written to you about this before, but you have not settled this matter. You should repay this money now, or contact us about how you will pay us back.

If We Do Not Hear From You

If you do not pay us or get in touch with us about this by XX/XX/XX, we will consider sending this case to the Office of the Inspector General or the United States Secret Service for possible prosecution.

If You Have Any Questions

If you have any questions, you may call us at 1-800-772-1213, or call your local Social Security office at XXX-XXXX. We can answer most questions over the phone. You may also write or visit any Social Security office. The office that serves your area is:

611 E 6th
Baltimore, MD 21200

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

Name

Assistant Regional Commissioner

Processing Center Operations

Enclosure:

Return Envelope