TN 72 (04-16)

Document Identifier for Aurora: E3119

A. Exhibit letter

We reviewed the overpayment determination and found it *F1. The enclosed Form SSA-662 explains our reasons. (E3119.1) 

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.

*F1

If we do not receive your refund within 30 days, we plan to recover the overpayment by withholding your full benefit starting with the payment you would normally receive about *F2. We will continue withholding your benefit until we fully recover the overpayment. (3100A)

Or

We will recover the overpayment from the payment you would receive about *F1. The reduced payment will be *F2. You will receive your regular monthly payment about *F3. (3100B)

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)

If you believe that the reconsideration determination is not correct, you may request a hearing before an administrative law judge of the Office of Disability Adjudication and Review. If you want a hearing you must request it not later than 60 days from the date you receive this notice. You should make your request through any Social Security office.

You have the right to request a determination concerning the need to recover the overpayment. This is called waiver. You may request waiver anytime. A request for waiver will be approved if both of the following are true:

1. The overpayment was not your fault in any way, and

2. You could not meet your necessary living expenses if we recovered the overpayment, or recovery would be unfair for some other reason.

If you request waiver, we may need a statement of your assets and monthly income and expenses.

If you request waiver within 30 days from the date of this notice, we will not start to withhold any part of your benefits. If you request waiver after 30 days, we will stop any withholding while we consider your waiver request. And, if we asked you to refund the overpayment, you won't have to make refund while your waiver request is being considered.

If you request waiver and after reviewing your request we cannot approve it, we will notify you in writing of our reasons.¹

A personal conference with a Social Security employee will then be scheduled for you so that you can explain why you do not believe your waiver request should be denied. More information about the personal conference is given in the notice if we cannot waive recovery of your overpayment.

If you disagree with the waiver decision you have other appeal rights. These appeal rights will also be explained in detail in the waiver determination notice. (E3119.2)

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)

Even if you do not want to request waiver or a hearing, call us at 1-800-772-1213 if the planned withholding of your benefit will cause hardship or you prefer to refund the overpayment balance so that withholding of your payment is not necessary. (3119C) Domestic

Or

Even if you do not want to request waiver or a hearing, please call, write or visit *F1 us at 1-800-772-1213 if the planned withholding of your benefit will cause hardship or you prefer to make full refund of the overpayment so that further withholding of your payment is not necessary. Please take this letter with you if you do visit an office. (3119D Foreign)

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 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 (3):
Form SSA-662
Form SSA-70-10281

Refund envelope³

¹ If the beneficiary lives outside the U.S., omit the next two sentences.

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

³ If overpayment is less than or equal to the monthly payment, omit refund envelope.

B. Requesting instructions

The person who makes a determination on the reconsideration request is responsible for requesting this notice and providing appropriate fill-ins.

E3119.1 Fill-Ins:

*F1-1 correct

*F1-2 correct in part

You must select one of the following UTIs:

• Use UTI 3100A if the overpayment exceeds the monthly payment.

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

• Use UTI 3100B if the overpayment is less than the monthly payment.

You must select one of the following UTIs:

• Use UTI 3119C if the person lives in the U.S.

• Use UTI 3119D if the person lives outside the U.S. Substitute a fill-in from paragraph 3901D in NL 00703.005E.

You must select one of the following UTIs:

• Use UTI CTDO if the person lives in the U.S.

• Use UTI 3901D if the person lives outside the U.S.

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