Important Information About Your Appeal, Waiver Rights and Repayment Options

OMB 0960-0779

SSA uses Form SSA-3105, Important Information About Your Appeal, Waiver Rights, and Repayment Options, to explain these rights to overpaid individuals and allow them to notify SSA of their decision(s) regarding these rights. The respondents are overpaid claimants requesting a waiver of recovery for the overpayment; reconsideration of the fact of the overpayment; or a lesser rate of withholding of the overpayment.

The latest form for Important Information About Your Appeal, Waiver Rights and Repayment Options expires 2022-02-28 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SSA-3105 Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form Form and Instruction
Supporting Statement - 0779 (Final).docx Supporting Statement A
Addendum - 0779 (Final).docx Supplementary Document
Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form Form and Instruction
Important Information About Your Appeal, Waiver Rights and Repayment Options - Debt Management System Other-Intranet Screens (phone call)

All Historical Document Collections

202108-0960-002	Revision of a currently approved collection	2022-01-13
201807-0960-017 Approved without change	Revision of a currently approved collection	2018-11-14
201507-0960-010 Approved without change	Revision of a currently approved collection	2015-10-16
201210-0960-005 Approved without change	Revision of a currently approved collection	2013-01-15
200910-0960-008 Approved without change	Existing collection in use without an OMB Control Number	2010-03-02

OMB Details

Important Information About Your Appeal, Waiver Rights and Repayment Options - Debt Management System

Federal Enterprise Architecture: Income Security - General Retirement and Disability