Important Information About Your Appeal And Waiver
Download a blank fillable Important Information About Your Appeal And Waiver in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Important Information About Your Appeal And Waiver with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Form Approved
Privacy Act Statement - Collection and
OMB NO. 0960-0779
A complete list of routine uses of the information
Use of Personal Information
you gave us is available in our Privacy Act
IMPORTANT INFORMATION ABOUT
Systems of Records Notices entitled, Claims Folder
YOUR APPEAL, WAIVER RIGHTS,
Sections 204, 1631(b), and 1870 of the Social
System, 60-0089, Master Beneficiary
AND REPAYMENT OPTIONS
Security Act, as amended, authorize us to collect
Record System, 60-0090, and 60-0094, Recovery of
this information. We will use the information you
Overpayments, Accounting and
If you think we made a mistake when we
provide to make a determination on waiving
Reporting/Debt Management System. Additional
decided that you were overpaid or in the
overpayment recovery or changing your repayment
information about these and other systems of
amount of the overpayment, you have the
rate.
records notices and our programs are available from
Furnishing us this information is voluntary. However,
right to ask us to look at the overpayment
failing to provide all or part of the
our Internet website at
decision again within 60 days of this notice.
information could prevent us from approving your
or at your local Social
This is called a RECONSIDERATION.
request.
Security office.
(See next page for an explanation.)
We rarely use the information you supply for any
purpose other than for determining a waiver or
Even if you agree that you were overpaid, you
change in the repayment rate of an overpayment
have the right to ask that we do not recover
recovery. However, we may also disclose
the overpayment. This is called a WAIVER.
information to another person or to another agency
Paperwork Reduction Act Statement -
(See next page for an explanation.)
in accordance with approved routine uses,
which include but are not limited to the following:
This information collection meets the
You have the right to ask for either
requirements of 44 U.S.C. § 3507, as
1. To enable a third party or an agency to assist
Reconsideration, Waiver, or both. You may
amended by section 2 of the Paperwork
Social Security in establishing rights to
also wish to use one of the repayment options
Reduction Act of 1995. You do not need to
Social Security benefits and/or coverage;
listed on page 4.
answer these questions unless we display a
2. To comply with Federal laws requiring the release
valid Office of Management and Budget
of information from Social Security
HOW TO REQUEST WAIVER OR
records (e.g., to the Government Accountability
control number. We estimate that it will take
RECONSIDERATION
Office and Department of Veterans
about 15 minutes to read the instructions,
Affairs);
gather the facts, and answer the questions.
You or someone who will represent you
3. To make determinations for eligibility in similar
should call, write or visit your local Social
health and income maintenance
SEND OR BRING THE COMPLETED FORM
Security office to help you complete the
programs at the Federal, State, and local level; and,
TO YOUR LOCAL SOCIAL SECURITY
4. To facilitate statistical research, audit, or
necessary forms which are:
OFFICE. You can find your local Social
investigative activities necessary to assure the
SSA-561-U2, Request for
Security office through SSA's website at
integrity and improvement of Social Security
Reconsideration
. Offices are also
programs (e.g., to the Bureau of Census and
to private entities under contract with us).
listed under U. S. Government agencies in
SSA-632-F4 Request for Waiver of
your telephone directory or you may call
Overpayment Recovery or Change
We may also use the information you provide in
Social Security at 1-800-772-1213 (TTY
in Repayment Rate
computer matching programs. Matching
1-800-325-0778). You may send comments
programs compare our records with records kept by
on our time estimate above to: SSA, 6401
You may find these forms online at www.
other Federal, State, or local government
Security Blvd, Baltimore, MD 21235-6401.
socialsecurity.gov If you want to request
agencies. Information from these matching
Send only comments relating to our time
Reconsideration or Waiver, but do not want to
programs can be used to establish or verify a
estimate to this address, not the
call or visit an office, fill out the tear-off form
person's eligibility for federally-funded or
completed form.
on the last page of this notice. Return the
administered benefit programs and for repayment of
incorrect payments or delinquent debts under these
completed form in the enclosed self-
programs.
addressed envelope.
6.
5.
1.
Form SSA-3105 (04-2013)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal