DI / DE 1447D

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Notice of Potential Overpayment

 
Mailing Date:
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Claim ID:
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CED:
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Office Number:
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The information shown below indicates that we may have overpaid you $ Blank Line in disability insurance benefits for the period beginning MM/DD/YYYY and ending MM/DD/YYYY.
We have the following information:
  • If you disagree with the information, please provide any information that will help us determine the validity of the overpayment.
  • If you agree you were overpaid benefits in the amount shown above and will be paying the amount in full, no further action is needed now. You will receive additional overpayment information with repayment instructions.
  • If you agree with the information, you can request that we waive the repayment requirement for this overpayment. To request a waiver, complete and return the enclosed financial statement. You must explain why you believe the potential overpayment was not due to fraud, misrepresentation, or willful nondisclosure on your part; or that the potential overpayment was received without your fault. If applicable, also explain how:
    1. You made changes in your financial status or circumstances (commitments) that you would not have made had you not received the benefits paid to you, or
    2. Repayment would impose extraordinary hardship on you or your family.
  • If you agree that you were overpaid benefits but cannot fully repay this overpayment now, complete and return the enclosed financial statement. This information will be used to establish an installment agreement. To request an installment agreement, please call the Benefit Overpayment Collection Section at 1-800-676-5737
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Field Office Address
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DE 1447D Rev. 8 (9-23) (INTRANET)