Form Ssa 3105 – Fill Out and Use This PDF

Page 5 of 6

Privacy Act Statement - Collection and Use

of Personal Information

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.

Page 6 of 6

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.

Paperwork Reduction Act Statement

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.

Form SSA-3105 (12-2017)

Discontinue Prior EditionsPage 1 of 6 Social Security Administration OMB No. 0960-0779

Important Information About Your Appeal, Waiver Rights, and Repayment Options

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.

How to Request Waiver or Reconsideration

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.

Reconsideration

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.

Waiver

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.

Page 3 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 4 of 6

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).

YOUR SOCIAL SECURITY CLAIM NUMBER

YOUR NAME (PRINT)

YOUR ADDRESS (PRINT)

YOUR DAYTIME TELEPHONE NO. (include area code)

DATE