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

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);
3. To facilitate statistical research, audit, or
investigative activities necessary to assure the
integrity of Social Security programs; and
4. To the Department of Justice when
representing the Social Security Administration
in litigation.
5.

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
See revised
and for repayment of payments or delinquent debts
under these programs. Privacy Act

Statement below.

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.

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.
Form SSA-3105 (01-2011)

1.

RECONSIDERATION

There is no time limit on your right to request
waiver.

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 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 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 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 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).
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 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.

YOUR SOCIAL SECURITY CLAIM NUMBER

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.

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

CITYand STATE

ZIP CODE

YOUR DAYTIME TELEPHONE NO. (include
area code)
DATE

Form SSA-3105 (01-2011)

4.

Privacy Act Statement
Collection and Use of Personal Information
Sections 204, 1631(b), and 1870 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 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.
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.