Fillable Ssa-3105 Important Information About Your Appeal, Waiver Rights, and Repayment Options

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Ssa-3105 Important Information About Your Appeal, Waiver Rights, and Repayment Options

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We may share the information you provide to other
agencies through computer matching programs.
Matching programs compare our records with
records kept by other Federal, State, or local
government agencies. We can use the information
from these matching programs to establish or verify
a person's eligibility for federally funded or
administered benefit programs and for repayment of
incorrect payments or delinquent debts under these
programs.
This information collection meets the requirements
of 44 U.S.C. § 3507, as amended by section 2 of
the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a
valid Office of Management and Budget control
number. We estimate that it will take about 15
minutes to read the instructions, gather the facts,
and answer the questions. SEND OR BRING THE
COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. You can find your local
Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed
under U. S. Government agencies in your
telephone directory or you may call Social
Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our
time estimate to this address, not the completed
form.
Sections 204 and 1631(b) of the Social Security
Act, as amended, authorize us to collect this
information. We will use the information you
provide to make a determination on waiving
overpayment recovery or changing your
repayment rate.
Furnishing us this information is voluntary.
However, failing to provide us with all or part of
the information could prevent us from making an
accurate decision on your benefits.
We rarely use the information you supply for any
purpose other than the reason stated above.
However, we may use the information for the
administration of our programs, including sharing
information:
1. To comply with Federal laws requiring the
release of information from Social Security
records (e.g., to the Government
Accountability Office and Department of
Veterans Affairs); and,
2. To facilitate statistical research, audit, or
investigative activities necessary to ensure the
integrity and improvement of our programs
(e.g., to the Bureau of the Census and to
private entities under contract with us)
A list of when we may share your information
with others, called routine uses, is available in
our System of Records Notices entitled, Claims
Folder System, 60-0089, Master Beneficiary
Record, 60-0090, and Recovery of
Overpayments, Accounting and Reporting/Debt
Management System, 60-0094. Additional
information about these and other system of
records notices and our programs, is available
on-line at www.socialsecurity.gov or at your local
Social Security office.
Privacy Act Statement - Collection and Use
of Personal Information
Page 5 of 6
Paperwork Reduction Act Statement
Page 6 of 6
If you think we made a mistake when we decided
that you were overpaid or in the amount of the
overpayment, you have the right to ask us to look
at the overpayment decision again within 60
days of this notice. This is called a
RECONSIDERATION. (See next page for an
explanation.)
Even if you agree that you were overpaid, you
have the right to ask that we do not recover the
overpayment. This is called a WAIVER. (See
next page for an explanation.)
You have the right to ask for either
Reconsideration, Waiver, or both. You may also
wish to use one of the repayment options listed
on page 4.
You or someone who will represent you should
call, write or visit your local Social Security office
to help you complete the necessary forms which
are:
• SSA-561-U2, Request for Reconsideration
• SSA-632-F4 Request for Waiver of
Overpayment Recovery or Change in
Repayment Rate
You may find these forms online at
www.socialsecurity.gov
. If you want to request
Reconsideration or Waiver, but do not want to
callor visit an office, fill out the tear-off form on
the last page of this notice. Return the
completed form in the enclosed self-addressed
envelope.
Important Information About Your Appeal,
Waiver Rights, and Repayment Options
How to Request Waiver or Reconsideration
Form SSA-3105 (12-2017)
Discontinue Prior Editions
Social Security Administration
Page 1 of 6
OMB No. 0960-0779
I am requesting a Reconsideration
(I disagree with the amount of the
overpayment or the fact that I was overpaid).
I am requesting a Waiver (the overpayment
was not my fault and I cannot afford to
repay).
I am requesting both Reconsideration and
Waiver.
I want $ withheld from my
monthly Social Security check to repay the
overpayment.
I am no longer receiving benefits and want to
repay the overpayment in monthly
installments. Enclosed is my first refund of
$ .
I am requesting an explanation of the
overpayment.
Other (Please explain on a separate sheet of
paper).
If you request Reconsideration, the overpayment
decision will be reviewed by a Social Security
employee who did not participate in the original
overpayment decision.
If you request Reconsideration within 30 days
from the date of this notice, we will not start to
withhold any part of your benefits. However, after
30 days we will start to withhold part or all of your
benefits.
If you request Reconsideration within 60 days
from the date of this notice, we will suspend any
withholding while the overpayment decision is
being reviewed. Also, if we asked you to refund
the overpayment, you will not have to make any
refund while the overpayment decision is being
reviewed.
If you do not appeal within the 60 day time limit,
you may lose your right to this appeal. If you
have a good reason (such as hospitalization) for
not appealing within the time limits, we may give
you more time. A request for more time must be
made to us in writing, stating the reason for the
delay.
If you request Waiver of recovery of the
overpayment and your request is approved, you
will not have to repay the overpayment.
We will approve your waiver request if:
1. The overpayment was not your fault and
repaying it would mean you could not pay your
necessary living expenses, OR
2. The overpayment was not your fault and
repaying it would be unfair to you.
Form SSA-3105 (12-2017)
Reconsideration
Waiver
Page 2 of 6
There is no time limit on your right to request
waiver.
If you request Waiver within 30 days from the date
of this notice, we will not start withholding any part
of your benefits.
If you request Waiver after 30 days, we will
suspend any withholding while we consider your
Waiver request. If we asked you to refund the
overpayment, you will not have to make any refund
while your waiver request is being considered.
If we cannot approve your Waiver request, we will
contact you to schedule a Personal Conference. At
that conference, you or your representative may
explain why you should not have to repay the
overpayment.
Also, you or your representative may present
witnesses on your behalf and, if you wish, question
any witnesses that we used in making the
determination being reviewed.
We will notify you in writing of the result of your
Waiver request, and whether you must repay the
overpayment. That notice will explain your right to
appeal. If you do not want a Personal Conference,
you still have the right to appeal. We will notify you
of other appeal rights.
BE SURE TO CALL THE SOCIAL SECURITY
ADMINISTRATION AT 1-800-772-1213 (TTY
1-800-325-0778) IF YOU HAVE ANY QUESTIONS
If you wish to mail your request for a
Reconsideration of the overpayment, Waiver of
recovery of the overpayment, or both; or if you wish
to use one of the repayment options listed in the
next column, please check the appropriate block, fill
out the identifying information and return it in the
enclosed self-addressed envelope.
Page 3 of 6
YOUR SOCIAL SECURITY CLAIM NUMBER
YOUR NAME (PRINT)
YOUR ADDRESS (PRINT)
CITY AND STATE ZIP CODE
YOUR DAYTIME TELEPHONE NO. (include area
code)
DATE
Page 4 of 6
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Ssa-3105 Important Information About Your Appeal, Waiver Rights, and Repayment Options

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Completed 1 October 2019

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