Form SSA-3105 Request Waiver or Reconsideration

Form SSA-3105 is a U.S. Social Security Administration form also known as the "Request Waiver Or Reconsideration". The latest edition of the form was released in December 1, 2017 and is available for digital filing.

Download a PDF version of the Form SSA-3105 down below or find it on U.S. Social Security Administration Forms website.

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Form SSA-3105 (12-2017)
Page 5 of 6
Page 6 of 6
Page 1 of 6
Discontinue Prior Editions
We may share the information you provide to other
Privacy Act Statement - Collection and Use
Social Security Administration
OMB No. 0960-0779
of Personal Information
agencies through computer matching programs.
Important Information About Your Appeal,
Matching programs compare our records with
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
government agencies. We can use the information
If you think we made a mistake when we decided
information. We will use the information you
from these matching programs to establish or verify
that you were overpaid or in the amount of the
provide to make a determination on waiving
overpayment, you have the right to ask us to look
a person's eligibility for federally funded or
overpayment recovery or changing your
at the overpayment decision again within 60
administered benefit programs and for repayment of
repayment rate.
days of this notice. This is called a
incorrect payments or delinquent debts under these
RECONSIDERATION. (See next page for an
Furnishing us this information is voluntary.
programs.
explanation.)
However, failing to provide us with all or part of
the information could prevent us from making an
Even if you agree that you were overpaid, you
accurate decision on your benefits.
have the right to ask that we do not recover the
Paperwork Reduction Act Statement
overpayment. This is called a WAIVER. (See
We rarely use the information you supply for any
next page for an explanation.)
purpose other than the reason stated above.
However, we may use the information for the
This information collection meets the requirements
administration of our programs, including sharing
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,
You or someone who will represent you should
and answer the questions. SEND OR BRING THE
call, write or visit your local Social Security office
COMPLETED FORM TO YOUR LOCAL SOCIAL
2. To facilitate statistical research, audit, or
to help you complete the necessary forms which
SECURITY OFFICE. You can find your local
investigative activities necessary to ensure the
are:
Social Security office through SSA’s website at
integrity and improvement of our programs
(e.g., to the Bureau of the Census and to
www.socialsecurity.gov. Offices are also listed
• SSA-561-U2, Request for Reconsideration
private entities under contract with us)
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).
Overpayment Recovery or Change in
with others, called routine uses, is available in
You may send comments on our time estimate
Repayment Rate
our System of Records Notices entitled, Claims
above to: SSA, 6401 Security Blvd, Baltimore, MD
Folder System, 60-0089, Master Beneficiary
21235-6401. Send only comments relating to our
Record, 60-0090, and Recovery of
You may find these forms online at
time estimate to this address, not the completed
Overpayments, Accounting and Reporting/Debt
www.socialsecurity.gov. If you want to request
form.
Management System, 60-0094. Additional
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 5 of 6
Page 6 of 6
Page 1 of 6
Discontinue Prior Editions
We may share the information you provide to other
Privacy Act Statement - Collection and Use
Social Security Administration
OMB No. 0960-0779
of Personal Information
agencies through computer matching programs.
Important Information About Your Appeal,
Matching programs compare our records with
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
government agencies. We can use the information
If you think we made a mistake when we decided
information. We will use the information you
from these matching programs to establish or verify
that you were overpaid or in the amount of the
provide to make a determination on waiving
overpayment, you have the right to ask us to look
a person's eligibility for federally funded or
overpayment recovery or changing your
at the overpayment decision again within 60
administered benefit programs and for repayment of
repayment rate.
days of this notice. This is called a
incorrect payments or delinquent debts under these
RECONSIDERATION. (See next page for an
Furnishing us this information is voluntary.
programs.
explanation.)
However, failing to provide us with all or part of
the information could prevent us from making an
Even if you agree that you were overpaid, you
accurate decision on your benefits.
have the right to ask that we do not recover the
Paperwork Reduction Act Statement
overpayment. This is called a WAIVER. (See
We rarely use the information you supply for any
next page for an explanation.)
purpose other than the reason stated above.
However, we may use the information for the
This information collection meets the requirements
administration of our programs, including sharing
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,
You or someone who will represent you should
and answer the questions. SEND OR BRING THE
call, write or visit your local Social Security office
COMPLETED FORM TO YOUR LOCAL SOCIAL
2. To facilitate statistical research, audit, or
to help you complete the necessary forms which
SECURITY OFFICE. You can find your local
investigative activities necessary to ensure the
are:
Social Security office through SSA’s website at
integrity and improvement of our programs
(e.g., to the Bureau of the Census and to
www.socialsecurity.gov. Offices are also listed
• SSA-561-U2, Request for Reconsideration
private entities under contract with us)
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).
Overpayment Recovery or Change in
with others, called routine uses, is available in
You may send comments on our time estimate
Repayment Rate
our System of Records Notices entitled, Claims
above to: SSA, 6401 Security Blvd, Baltimore, MD
Folder System, 60-0089, Master Beneficiary
21235-6401. Send only comments relating to our
Record, 60-0090, and Recovery of
You may find these forms online at
time estimate to this address, not the completed
Overpayments, Accounting and Reporting/Debt
www.socialsecurity.gov. If you want to request
form.
Management System, 60-0094. Additional
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
There is no time limit on your right to request
I am requesting a Reconsideration
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
YOUR SOCIAL SECURITY CLAIM NUMBER
overpayment. That notice will explain your right to
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.
YOUR ADDRESS (PRINT)
If you request Waiver of recovery of the
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
CITY AND STATE
ZIP CODE
Reconsideration of the overpayment, Waiver of
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
YOUR DAYTIME TELEPHONE NO. (include area
necessary living expenses, OR
next column, please check the appropriate block, fill
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.

Download Form SSA-3105 Request Waiver or Reconsideration

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