TN 67 (07-15)

Document Identifier for Aurora: E3106

DPS Notice: Notice of Overpaid Person in Pay/Nonpay Title 2

A. Exhibit letter

We paid you $*F1 more in *F2 benefits than you were due.*F3 (E3106.1)
How To Pay Us Back

Please refund this overpayment within 30 days. Make your check
or money order payable to "Social Security Administration."
Include the claim number shown above on the check or money
order, and send it to us in the enclosed envelope. If you
cannot refund the full $*F1 now, please submit (a) a partial
payment; (b) an explanation of your financial situation; and (c)
a definite plan to repay the balance. (3106E)
*F2

(Use the UTI below only when the beneficiary is receiving other program benefits)

Instead of sending us a refund, we can withhold part or all of
your overpayment from your *F1. This method of repayment is
voluntary. You may stop the withholding at any time. We will
not change your *F2 if you do not choose this method of
repayment. If you want us to withhold the overpayment from your
*F3, please get in touch with us right away. (3106A)

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 office ¹.
  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.
  
  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. (3106B)

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 you have any questions. (3106C 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 (1) if you have any questions. Please take this letter with you if you do visit an office. (3106D Foreign)

If You Want Help With Your Appeal² (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)

Suspect Social Security Fraud?
Please visit http://oig.ssa.gov/r 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)

Enclosures (2):

SSA-3105

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:

E3106.1 Fill-Ins

*F1-1 Amount of overpayment
*F2-1 Social Security
*F2-2 Black Lung
*F3-1 Explanation of Overpayment-dictated text

Use UTI 3106A if the liable individual is receiving other program benefits (e.g., a person liable for repayment of a title II overpayment receives Black Lung or title XVI payments).

3106A Fill-Ins:

*F1-1 Type of Benefit
*F2-1 Type of Benefit
*F3-1 Type of Benefit

Use 3106D if the person is outside the U.S.

3106D Fill-Ins:

Use a fill-in from paragraph 3901D in NL 00703.005E.

3106E Fill-Ins:

*F1-1 Amount of overpayment
*F2-1 3100FC

Use 3100FC if the person is outside the U.S.

¹ If the person lives outside the U.S., substitute a fill-in from paragraph 3901D in NL 00703.005 E.

² If the person lives outside the U.S. or has an attorney, omit this paragraph.