TN 17 (02-93)

A. Introduction

The Certificate of Indebtedness is a complete statement of how the overpayment occurred.

B. Procedure

1. Number of copies and format

Prepare an original and 3 copies of the Certificate of Indebtedness in the format in GN 02215.260 for the signature of the ARC, PCO (PSC) or Director, ODIO.

2. Distribution of copies

Forward the original attached to the Claims Collection Litigation Report, (CCLR) and 2 copies to the ARC, POS. File 1 copy on the left side of the claims folder.

3. Special information to include

Include in general terms the appropriate section of the Act giving rise to the overpayment.

If conserved benefits are involved, describe the payments made to the payee (e.g., the monthly rate, dates of payments). State the regulatory authority from which the claim arose (e.g., Section 404.1610 of Regulations No. 4 of the Social Security Administration).

Include any administrative decisions (e.g., waiver denial, affirmation of overpayment on reconsideration). Do not include SSA attempts to collect the debt. This information will be included in the CCLR.

Explain any adjustment or refund which reduced the original overpayment to the amount being referred for enforced collection.

C. Reference

For completion of the CCLR, see GN 02215.168.