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.
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.
2.

I am requesting a Reconsideration (I
disagree with the amount of the
overpayment or the fact that I was
overpaid).

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 selfaddressed envelope.
3.

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).
YOUR SOCIAL SECURITY CLAIM NUMBER

YOUR NAME (PRINT)

YOUR ADDRESS (PRINT)

CITY and STATE

ZIP CODE

YOUR DAYTIME TELEPHONE NO. (include
area code)
DATE

4.
Form SSA-3105 (04-2013)

Privacy Act Statement - Collection and
Use of Personal Information

See
Revised
Sections 204, 1631(b), and
1870
of the Social
Privacy
Security Act, as amended,
authorizeAct
us to collect
this information. We will use
the
information
you
Statement
provide to make a determination on waiving
overpayment recovery or changing your repayment
rate.
Furnishing us this information is voluntary. However,
failing to provide all or part of the
information could prevent us from approving your
request.
We rarely use the information you supply for any
purpose other than for determining a waiver or
change in the repayment rate of an overpayment
recovery. However, 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);
3. To make determinations for eligibility in similar
health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or
investigative activities necessary to assure the
integrity and improvement of Social Security
programs (e.g., to the Bureau of Census and
to private entities under contract with us).
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
incorrect payments or delinquent debts under these
programs.
5.

A complete list of routine uses of the information
you gave us is available in our Privacy Act
Systems of Records Notices entitled, Claims Folder
System, 60-0089, Master Beneficiary
Record System, 60-0090, and 60-0094, Recovery of
Overpayments, Accounting and
Reporting/Debt Management System. Additional
information about these and other systems of
records notices and our programs are available from
our Internet website at
www.socialsecurity.gov or at your local Social
Security office.

See Revised PRA
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.
6.

Form Approved
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
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 selfaddressed envelope.
1.

Form SSA-3105 (04-2013)

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 1800-325-0778). 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.

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
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.
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.