Page 5 of 6 Page 6 of 6 Form SSA-3105 (12-2017)

Discontinue Prior Editions Page 1 of 6

Privacy Act Statement - Collection and Use We may share the information you provide to other Social Security Administration OMB No. 0960-0779
of Personal Information agencies through computer matching programs.
Matching programs compare our records with Important Information About Your Appeal,
Sections 204 and 1631(b) of the Social Security Waiver Rights, and Repayment Options
records kept by other Federal, State, or local
Act, as amended, authorize us to collect this
information. We will use the information you government agencies. We can use the information If you think we made a mistake when we decided
provide to make a determination on waiving from these matching programs to establish or verify that you were overpaid or in the amount of the
overpayment recovery or changing your a person's eligibility for federally funded or overpayment, you have the right to ask us to look
repayment rate. administered benefit programs and for repayment of at the overpayment decision again within 60
incorrect payments or delinquent debts under these days of this notice. This is called a
Furnishing us this information is voluntary. programs. RECONSIDERATION. (See next page for an
However, failing to provide us with all or part of explanation.)
the information could prevent us from making an
accurate decision on your benefits. Even if you agree that you were overpaid, you
have the right to ask that we do not recover the
We rarely use the information you supply for any Paperwork Reduction Act Statement overpayment. This is called a WAIVER. (See
purpose other than the reason stated above. next page for an explanation.)
However, we may use the information for the
administration of our programs, including sharing This information collection meets the requirements You have the right to ask for either
information: of 44 U.S.C. § 3507, as amended by section 2 of Reconsideration, Waiver, or both. You may also
the Paperwork Reduction Act of 1995. You do not wish to use one of the repayment options listed
1. To comply with Federal laws requiring the need to answer these questions unless we display a on page 4.
release of information from Social Security valid Office of Management and Budget control
records (e.g., to the Government number. We estimate that it will take about 15
Accountability Office and Department of How to Request Waiver or Reconsideration
minutes to read the instructions, gather the facts,
Veterans Affairs); and,
and answer the questions. SEND OR BRING THE You or someone who will represent you should
COMPLETED FORM TO YOUR LOCAL SOCIAL call, write or visit your local Social Security office
2. To facilitate statistical research, audit, or
SECURITY OFFICE. You can find your local to help you complete the necessary forms which
investigative activities necessary to ensure the
integrity and improvement of our programs Social Security office through SSA’s website at are:
(e.g., to the Bureau of the Census and to www.socialsecurity.gov. Offices are also listed
private entities under contract with us) • SSA-561-U2, Request for Reconsideration
under U. S. Government agencies in your
telephone directory or you may call Social • SSA-632-F4 Request for Waiver of
A list of when we may share your information Security at 1-800-772-1213 (TTY 1-800-325-0778).
with others, called routine uses, is available in Overpayment Recovery or Change in
You may send comments on our time estimate Repayment Rate
our System of Records Notices entitled, Claims
Folder System, 60-0089, Master Beneficiary above to: SSA, 6401 Security Blvd, Baltimore, MD
Record, 60-0090, and Recovery of 21235-6401. Send only comments relating to our
You may find these forms online at
Overpayments, Accounting and Reporting/Debt time estimate to this address, not the completed
www.socialsecurity.gov. If you want to request
Management System, 60-0094. Additional form. Reconsideration or Waiver, but do not want to
information about these and other system of callor visit an office, fill out the tear-off form on
records notices and our programs, is available the last page of this notice. Return the
on-line at www.socialsecurity.gov or at your local completed form in the enclosed self-addressed
Social Security office. envelope.
Form SSA-3105 (12-2017) Page 2 of 6 Page 3 of 6 Page 4 of 6

Reconsideration There is no time limit on your right to request I am requesting a Reconsideration

waiver. (I disagree with the amount of the
If you request Reconsideration, the overpayment overpayment or the fact that I was overpaid).
decision will be reviewed by a Social Security If you request Waiver within 30 days from the date
employee who did not participate in the original of this notice, we will not start withholding any part I am requesting a Waiver (the overpayment
overpayment decision. of your benefits. was not my fault and I cannot afford to
repay).
If you request Reconsideration within 30 days If you request Waiver after 30 days, we will
from the date of this notice, we will not start to suspend any withholding while we consider your I am requesting both Reconsideration and
withhold any part of your benefits. However, after Waiver request. If we asked you to refund the Waiver.
30 days we will start to withhold part or all of your overpayment, you will not have to make any refund
benefits. while your waiver request is being considered. I want $ withheld from my
monthly Social Security check to repay the
If you request Reconsideration within 60 days If we cannot approve your Waiver request, we will overpayment.
from the date of this notice, we will suspend any contact you to schedule a Personal Conference. At
withholding while the overpayment decision is that conference, you or your representative may I am no longer receiving benefits and want to
being reviewed. Also, if we asked you to refund explain why you should not have to repay the repay the overpayment in monthly
the overpayment, you will not have to make any overpayment. installments. Enclosed is my first refund of
refund while the overpayment decision is being $ .
reviewed. Also, you or your representative may present
witnesses on your behalf and, if you wish, question I am requesting an explanation of the
If you do not appeal within the 60 day time limit, any witnesses that we used in making the overpayment.
you may lose your right to this appeal. If you determination being reviewed.
have a good reason (such as hospitalization) for Other (Please explain on a separate sheet of
not appealing within the time limits, we may give We will notify you in writing of the result of your paper).
you more time. A request for more time must be Waiver request, and whether you must repay the
made to us in writing, stating the reason for the overpayment. That notice will explain your right to YOUR SOCIAL SECURITY CLAIM NUMBER
delay. appeal. If you do not want a Personal Conference,
you still have the right to appeal. We will notify you YOUR NAME (PRINT)
Waiver
of other appeal rights.

If you request Waiver of recovery of the YOUR ADDRESS (PRINT)

BE SURE TO CALL THE SOCIAL SECURITY
overpayment and your request is approved, you ADMINISTRATION AT 1-800-772-1213 (TTY
will not have to repay the overpayment. 1-800-325-0778) IF YOU HAVE ANY QUESTIONS

We will approve your waiver request if: If you wish to mail your request for a
Reconsideration of the overpayment, Waiver of CITY AND STATE ZIP CODE
1. The overpayment was not your fault and recovery of the overpayment, or both; or if you wish
repaying it would mean you could not pay your to use one of the repayment options listed in the
necessary living expenses, OR next column, please check the appropriate block, fill YOUR DAYTIME TELEPHONE NO. (include area
code)
out the identifying information and return it in the
2. The overpayment was not your fault and enclosed self-addressed envelope. DATE
repaying it would be unfair to you.