Form SSA-3105 Important Information About Your Appeal, Waiver Rights,

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.

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 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 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.

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.
2.

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.
I am enclosing a full refund of the
overpayment.
Other (Please explain on a separate
sheet of paper).

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.

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.
3.

YOUR SOCIAL SECURITY CLAIM NUMBER

___ ___ ___ / ___ ___ / ___ ___ ___ ___
YOUR NAME (PRINT)

YOUR ADDRESS (PRINT)

CITYand STATE

ZIP CODE

YOUR DAYTIME TELEPHONE NO. (include
area code)
DATE
Form SSA-3105 (XX-2009)

4.

Privacy Act Statement - Collection and
Use of Personal Information
Sections 204, 1631(b), and 1870 of the Social Security
Act, as amended, and the Federal Coal Mine Health and
Safety Act of 1969 authorize us to collect this
information. The information you provide will be used to
make a determination on waiving overpayment recovery
or changing your repayment rate.
The information you furnish on this form is voluntary.
However, failure to provide the requested information
may prevent us from approving your request.
We rarely use the information you supply for any
purpose other than for determining waiver or a change
in the repayment rate of an overpayment recovery.
However, we may use it for the administration and
integrity of Social Security programs. We may also
disclose information to another person or to another
agency in accordance with approved routine uses,
which include but are not limited to the following:
1. To enable a third party or an agency to assist Social
Security in establishing rights to Social Security benefits
and/or coverage;
2. 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);

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.

3. To facilitate statistical research, audit, or investigative
activities necessary to assure the integrity of Social
Security programs; and

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

4. To the Department of Justice when representing the
Social Security Administration in litigation.

SSA-632-F4, Request for Waiver of
Overpayment Recovery or Change
in Repayment Rate

We may also use the information you provide in computer
matching programs. Matching programs compare our
records with records kept by other Federal, State, or local
government agencies. Information from these matching
programs can be used to establish or verify a person's
eligibility for Federally funded or administered benefit
programs and for repayment of payments or delinquent
debts under these programs.

You may find these forms online at
If you want to
www.socialsecurity.gov.
request Reconsideration or Waiver, but do
not want to call or 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.

Additional information regarding this form, routine uses of
information, and our programs and systems, is available
on-line at www.socialsecurity.gov or at your local Social
Security office.

5.

IMPORTANT INFORMATION
ABOUT YOUR APPEAL, WAIVER
RIGHTS, AND REPAYMENT OPTIONS

6.

1.