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Get SSA-3105 2017-2024

Return the Form SSA-3105 04-2013 If you request Reconsideration the participate in the original overpayment decision. from the date of this notice we will not start to withhold any part of your benefits. 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 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 records notices and our programs are available from our Internet website 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 listed under U* S* Government agencies in your telephone directory or you may call 1-800-325-0778.

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