Overpayment Response Checklist worksheet
Use this checklist to organize notice, amount, reason, waiver, reconsideration, budget, and payment plan.
| Item | Your notes |
|---|---|
| Use This Checklist To Organize Notice | ____________________________ |
| Amount | ____________________________ |
| Reason | ____________________________ |
| Waiver | ____________________________ |
| Reconsideration | ____________________________ |
| Budget | ____________________________ |
| Payment Plan | ____________________________ |
| Notice date | ____________________________ |
| Benefit program | ____________________________ |
| Payment period | ____________________________ |
| Amount shown by SSA | ____________________________ |
| Amount received | ____________________________ |
Before you use this checklist
- Copy dates and instructions from the current SSA notice rather than memory.
- Keep originals and work from copies.
- Do not send Social Security numbers, bank information, or full medical files to an unverified recipient.
- Save filing confirmations and proof of any time-sensitive submission.