NL: Notices, Letters and Paragraphs
TN 9 (06-18)
OPT028 NEW OVERPAYMENT AMOUNT INCLUDES PRIOR OVERPAYMENT (M05)
(Requested)
Caption: Your Benefits
However, the total overpayment is (1) , which includes a prior overpayment of (2) .
Fill-in values:
Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢
Total overpayment
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Current balance of prior overpayment
OPT107 OVERPAYMENT RECOVERED FROM ONE MONTH'S BENEFIT (A57)
(Requested)
Caption: Your Benefits
We will withhold (1) (2) (3) (4) payment to recover the money we (5) (6) . This is the payment you would normally receive about (7) .
Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: null
Fill-in (2) – Systems Generated
Choice 1: null
Fill-in (3) – Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Choice 4: Beneficiary's name
Fill-in (4) – Systems Generated
month and year (MM/CCYY)
Fill-in (5) – Systems Generated
Choice 1: overpaid
Choice 2: incorrectly paid
Fill-in (6) – Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Choice 4: Beneficiary's name
Fill-in (7) – Systems Generated
month and year (MM/CCYY)
OPT122 BENEFICIARY OVERPAID DUE TO SUSPENSION/TERMINATION (M13)
(Requested)
Caption: Your Benefits
Since we did not stop (1) payments until (2) , (3) paid (4) too much in benefits.
Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: Beneficiary's Name (possessive)
Choice 2: your
Fill-in (2) – Systems Generated
MM/CCYY
Fill-in (3) – Systems Generated
Choice 1: he was
Choice 2: she was
Choice 3: you were
Fill-in (4) Requested As A Money Amount In Format $$$$$.¢¢
Choice 1: Amount of overpayment
OPT127 UNDERPAYMENT USED TO REDUCE/RECOVER AN OVERPAYMENT (M03)
(Requested)
Caption: Your Benefits
We used (1) of (2) benefits to recover (3) of an overpayment on this record.
Fill-in values:
Fill-in (1) - Requested As A Money Amount in Format $$$$$.¢¢
Amount used for recovery
Fill-in (2) - Requested As A One Position Alpha Character or Language
Choice 1: (A) your
Choice 2: Name of Beneficiary
Fill-in (3) - Requested As A One Position Alpha Character
Choice 1: (A) all
Choice 2: (B) part
OPT132 DIRECT DEPOSIT — JOINT ACCOUNT — RECOVERY OF PAYMENTS MADE AFTER DEATH (A16)
(Requested)
Caption: Your Benefits
We paid (1) more in benefits than we should have. We deposited (2) benefits for (3) into a bank account which (4) also owned. We can't pay benefits for the month of death, (5) , or later. Because (6) a joint owner of the bank account, (7) overpaid (8) .
Fill-in values:
Fill-in (1) Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (2) Requested
Full name of the deceased beneficiary, possessive
Fill-in (3) Requested As A Date In Format Shown Below
Month(s) and year(s) of incorrect payment
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: Beneficiary's first name
Fill-in (5) Requested
Month(s) and year(s) of incorrect payment
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (6) Systems Generated
Choice 1: Beneficiary's name is
Choice 2: you are
Fill-in (7) Systems Generated
Choice 1: Beneficiary's name is
Choice 2: you are
Fill-in (8) Requested
Amount of overpayment
OPT148 CROSS PROGRAM RECOVERY - T16 UNDERPAYMENT USED TO RECOVER T2 OVERPAYMENT (B88)
(System Generated)
Caption: Your Benefits
We used (1) of (2) SSI benefits to recover some or all of an overpayment on this record.
Fill-in values:
Fill-in (1)
Amount of SSI under payment
Fill-in (2)
Choice 1: Beneficiary's Name possessive
Choice 2: your
OPT149 CROSS PROGRAM RECOVERY - T16 UNDERPAYMENT NOT USED TO REDUCED/RECOVER A T2 OVERPAYMENT (B89)
(System Generated)
Caption: What We Will Pay
We did not use any of 1 SSI benefits to recover an overpayment on this record.
Fill-in values:
Fill-in (1)
Choice 1: Beneficiary's Name
Choice 2: your
OPT151 OVERPAYMENT LIABILITY INFORMATION TO A REPRESENTATIVE PAYEE FOR OVERPAID BENEFICIARY (A27)
(Requested)
Caption: Your Benefits
As representative payee, you are personally liable for repayment unless you used the overpaid funds for the benefit of (1) , and the overpayment was made through no fault of your own.
Fill-in values:
Fill-in (1) – Systems Generated
Name(s) of beneficiary (ies)
OPT152 REPAY BENEFITS WITHHELD - PROTEST OF OVERPAYMENT RECEIVED TIMELY (LAF D to C ) (A44)
(Requested)
Caption: Your Benefits
We are paying (1) again beginning (2) because (3) asked us to review our overpayment decision. If we later find that our decision was correct, or that we cannot waive the overpayment, (4) will have to pay back the (5) which (6) . Someone from the local Social Security office will contact (7) to discuss the overpayment.
Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) - Requested As A Date In Format Shown Below
Date payments resumed MM/CCYY
Fill-in (3) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) – Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (6) – Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes
Fill-in (7) – Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
OPT153 OVERPAYMENT WITHHELD FROM BENEFITS IS REPAID — PROTEST RECEIVED TIMELY (A46)
(Requested)
Caption: Your Benefits
(1) asked us to review our overpayment decision. While we review (2) case, we are sending (3) the money we withheld from (4) checks.
If we later find that our decision was correct, or that we cannot waive the overpayment, (5) will have to pay back the (6) which (7) . Someone from the local Social Security office will contact (8) to discuss the overpayment.
Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: You
Choice 2: Beneficiary's Name
Fill-in (2) – Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) – Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (4) – Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment-
Fill-in (7) – Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes
Fill-in (8) – Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
OPT154 OVERPAYMENT PROTESTED - BENEFITS RESUMED AND WITHHELD BENEFITS REPAID - FOREIGN CLAIMS (A47)
(Requested)
Caption: Your Benefits
We are paying (1) again beginning (2) because (3) asked us to review our overpayment decision. If we later find that our decision was correct, or that we cannot waive the overpayment, (4) will have to pay back the (5) which (6) .
Fill-in values:
Fill-in (1) – Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2) – Requested As A Date In Format Shown Below
Date payments resumed MM/CCYY
Fill-in (3) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) – Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) – Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (6) – Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes
OPT155 OVERPAYMENT PROTESTED - BENEFITS RESUMED - MONEY WITHHELD NOT REPAID - FOREIGN CLAIMS (A48)
(Requested)
Caption: Your Benefits
We are paying (1) again beginning (2) because (3) asked us to review our overpayment decision. For now, we are still withholding the money which we already subtracted from (4) checks.
If we later find that our decision was correct, or that we cannot waive the overpayment, (5) will have to pay back the (6) which (7) .
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) – Requested As A Date In Format Shown Below
Date payments resumed MM/CCYY
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the remaining overpayment
Fill-in (7) Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes
OPT156 OVERPAYMENT PROTESTED AFTER RECOVERY COMPLETED/STOPPED - REPAY BENEFITS WITHHELD - FOREIGN CLAIMS (A49)
(Requested)
Caption: Your Benefits
(1) asked us to review our overpayment decision. While we review (2) case, we are sending (3) the money we withheld from (4) checks. If we later find that our decision was correct, or that we cannot waive the overpayment, (5) will have to pay back the (6) which (7) .
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: You
Choice 2: Beneficiary's Name
Fill-in (2) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
Fill-in (7) Systems Generated
Choice 1: you owe
Choice 2: he owes
Choice 3: she owes
OPT158 INTRODUCTORY STATEMENT FOR CAT A-A22 NOTICE WHEN OVERPAYMENT ESTABLISHED AND ALIEN TAXATION INVOLVED (ADMINISTRATIVE ADJUSTMENT) (F70)
(Requested)
Caption: None
We are writing to give (1) new information about the (2) benefits which (3) on this Social Security record. In the rest of this letter, we will tell (4) :
How we paid (5) (6) too much in benefits; and
What to do if (7) we are wrong about the overpayment.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) Requested As A One Position Alpha Character
Choice 1: (A) disability
Choice 2: (B) retirement
Choice 3: (C) survivor
Choice 4: (D) auxiliary
Fill-in (3) Systems Generated
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
Fill-in (7) Systems Generated
Choice 1: you think
Choice 2: he thinks
Choice 3: she thinks
OPT159 A21 NOTICE OVERPAYMENT RECOVERY (G51)
(System Generated)
Caption: Your Benefits
As we told (1) in our previous letter, we are withholding (2) benefits to recover the overpayment of (3) .
Fill-in values:
Fill-in (1)
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2)
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (3)
Amount of the overpayment
OPT161 INTRODUCTORY PARAGRAPH E31 AND E32 NOTICES (G70)
(System Generated)
Caption: None
We are writing to give (1) new information about the (2) benefits which (3) on this Social Security record. In the rest of this letter, we will tell (4) :
How we paid (5) (6) too much in benefits; and
What to do if (7) we are wrong about the overpayment.
Fill-in values:
Fill-in (1)
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2)
Choice 1: disability
Choice 2: retirement
Choice 3: survivor
Fill-in (3)
Choice 1: you receive
Choice 2: he receives
Choice 3: she receives
Fill-in (4)
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5)
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6)
Amount of the overpayment
Fill-in (7)
Choice 1: you think
Choice 2: he thinks
Choice 3: she thinks
OPT162 E31 AND E34 NOTICES MBP GREATER THAN OVERPAYMENT (G71)
(System Generated)
Caption: Your Benefits
We plan to collect the overpayment from the check which (1) will receive around (2) . We will reduce (3) check to (4) . We will send (5) (6) regular monthly benefit amount again beginning (7) .
Fill-in values:
Fill-in (1)
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (2)
MM/DD/CCYY
Fill-in (3)
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (4)
Amount of the check
Fill-in (5)
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6)
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (7)
MM/CCYY
OPT163 E34 NOTICE INTRODUCTORY PARAGRAPH (G72)
(System Generated)
Caption: None
We are writing to give (1) new information about Social Security benefits on this record. We paid (2) (3) too much in Social Security benefits. In the rest of this letter, we will tell you:
How we paid too much in benefits, and
What to do if you think we are wrong about the overpayment.
Fill-in values:
Fill-in (1)
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2)
Beneficiary's name
Fill-in (3)
Amount of the Overpayment
OPT164 OVERPAYMENT RECOVERY PROPOSED AGAINST OTHER BENEFICIARY E34 NOTICE (G73)
(System Generated)
Caption: None
We cannot recover the overpayment from the person who was overpaid. For this reason, we will withhold the money from the checks of other persons who are paid on the same Social Security record.
Fill-in values:
None
OPT165 CHECK PARAGRAPH FUTURE WITHHOLDING OF OVERPAYMENT (G91)
(System Generated)
Caption: Your Benefits
We will pay (1) a monthly check of (2) until we start to collect the overpayment.
Fill-in values:
Fill-in (1)
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (2)
PMA or CMA in $$$$$.¢¢ format
OPT166 PREVIOUS CHECK WAS INCORRECT AMOUNT (M02)
(Requested)
Caption: Your Benefits
The check (1) received for (2) in (3) should have been for (4) . Therefore we paid (5) (6) more in benefits than (7) due.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) – Requested As A Money Amount In Format $$$$$.¢¢
Amount of check
Fill-in (3) Requested As A Date In Format Shown Below
MM/CCYY
Fill-in (4) Requested As A Money Amount In Format $$$$$.¢¢
Amount that should have been paid
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (7) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
OPT167 OVERPAYMENT RECOVERED (M06)
(Requested)
Caption: Your Benefits
We have recovered all of the money (1) owed because of an overpayment.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
OPT168 OVERPAYMENT BALANCE (M08)
(Requested)
Caption: Your Benefits
The total amount of the overpayment is (1) .
Fill-in values:
Fill-in (1) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
OPT169 INCORRECT BENEFIT CAUSED INCORRECT PAYMENT, OVERPAYMENT OR UNDERPAYMENT (M10)
(Requested)
Caption: Your Benefits
Since we paid (1) (2) for (3) , we paid (4) (5) (6) than (7) due.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount paid
Fill-in (3) Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
Fill-in (6) - Requested As A One Position Alpha Character
Choice 1: (A) more
Choice 2: (B) less
Fill-in (7) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
OPT170 BENEFITS DEFERRED TO RECOVER AN INCORRECT PAYMENT/OVERPAYMENT (M11)
(Requested)
Caption: Your Benefits
We are withholding all of (1) benefits for (2) and (3) of (4) benefits for (5) to recover the (6) that was not due
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: your
Choice 2: Beneficiary's Name possessive
Fill-in (2) Requested As A Date In Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (3) Requested As A Money Amount In Format $$$$$.¢¢
Amount of final adjustment
Fill-in (4) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (5) Requested As A Date In Format Shown Below
MM/CCYY of final adjustment
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment or incorrect payment
OPT171 OTHER BENEFICIARY OVERPAID DUE TO WORK (M12)
(Requested)
Caption: Your Benefits
We paid (1) (2) too much in benefits because of work and earnings in (3) .
Fill-in values:
Fill-in (1) - Requested As A Language
Name of overpaid beneficiary
Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢
Amount of overpayment
Fill-in (3) - Requested As A Date In Format Shown Below
CCYY
OPT179 PAID VS. PAYABLE (M01)
(Requested)
Caption: Your Benefits
We paid (1) (2) for (3) . Since we should have paid (4) (5) for (6) , we paid (7) (8) (9) than (10) due.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's Name
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (3) Requested As A Date in Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) Requested As A Money Amount In Format $$$$$.¢¢
Correct Amount
Fill-in (6) Requested As A Date in Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (7) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (8) Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (9) Systems Generated
Choice 1: more
Choice 2: less
Fill-in (10) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
OPT180 FOREIGN REFUND REQUEST ADJUSTMENT PROPOSED OVERPAYMENT EXCEEDS MBP (F24)
(System Generated)
Caption: How To Pay Us Back
You should refund this overpayment within 30 days. Please make your check or money order payable to “Social Security Administration” and send it to us in the enclosed envelope.
Always include (1) Social Security claim number on the check or money order.
Please send your check or money order in United States currency or in local currency equal to the United States dollars. When you pay us in local currency, we use the exchange rate in effect at the time we get your payment. If this causes a difference between the amount you pay us and the amount you owe us, we will let you know. If you cannot mail your payment directly to us, please contact your Federal Benefits Unit for help in making the refund. Visit (2) for a list of Federal Benefits Units.
If we do not receive your refund within 30 days, we plan to recover the overpayment by withholding (3) full benefit each month beginning with the benefit (4) would normally receive about (5) . We will continue to withhold (6) benefit until the overpayment is fully recovered.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: your
Choice 2: Beneficiary Name possessive
Fill-in (2) Systems Generated
Choice 1: www.socialsecurity.gov/foreign/foreign.htm
Fill-in (3) Systems Generated
Choice 1: your
Choice 2: Beneficiary Name possessive
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (5) Systems Generated
MM/DD/CCYY
Fill-in (6) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
OPT181 (M07) DUPLICATE CHECK OVERPAYMENT
(Requested)
Caption: Your Benefits
We sent (1) two checks for (2) , both in the amount of (3) and both checks were cashed. Since (4) due only one check, we paid (5) (6) too much in benefits.
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: you
Choice 2: Beneficiary's name
Fill-in (2) Requested As A Date in Format Shown Below
MM/CCYY
Fill-in (3) Requested As A Money Amount In Format $$$$$.¢¢
Amount
Fill-in (4) Systems Generated
Choice 1: you were
Choice 2: he was
Choice 3: she was
Fill-in (5) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (6) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
OPT182 PRIOR OVERPAYMENT — WORK MONTHS PREVENTED RECOVERY (A29)
(Requested)
Caption: Your Benefits
Our records show that we paid (1) (2) too much in (3) . In our previous letter, we told (4) that we would withhold benefits in (5) to recover (6) amount. But (7) recent report shows that (8) worked during (9) . Because of that work, no benefits were payable for that period. Since we could not use benefits for those months to recover the amount (10) owed, (11) us (12) .
Fill-in values:
Fill-in (1) Systems Generated
Choice 1: Beneficiary's name
Choice 2: you
Fill-in (2) Requested As A Money Amount In Format $$$$$.¢¢
Amount of the overpayment
Fill-in (3) Requested As A Date in Format Shown Below
Year of prior overpayment in CCYY
Fill-in (4) Systems Generated
Choice 1: you
Choice 2: him
Choice 3: her
Fill-in (5) Requested As A Date in Format Shown Below
Choice 1: MM/CCYY
Choice 2: MM/CCYY through MM/CCYY
Fill-in (6) Requested As A One Position Alpha Character
Choice 1: (A) this
Choice 2: (B) part of this
Fill-in (7) Systems Generated
Choice 1: your
Choice 2: his
Choice 3: her
Fill-in (8) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (9) Requested As A Date in Format Shown Below
Choice 1: month and year of work MM/CCYY
Choice 2: months and years of work MM/CCYY through MM/CCYY
Fill-in (10) Systems Generated
Choice 1: you
Choice 2: he
Choice 3: she
Fill-in (11) Systems Generated
Choice 1: you still owe
Choice 2: he still owes
Choice 3: she still owes
Fill-in (12) Requested As A Money Amount In Format $$$$$.¢¢
Overpayment Amount