Program
Case Name
Branch
Case Number
Date of Notice
Prime Number
Worker ID
Program that has Overpayment:
Notice of Overpayment
and Planned Action
You have received services or other benefits that you were not eligible to
.
receive, in the amount of $
Even if this overpayment was not your fault, or if you did not know you were being
overpaid, you must pay this amount back to us. You can ask your worker how we
determined your overpayment. If your overpayment happened because you did not
report money from work, or if you reported it late, you may claim “good cause.”
Good cause means you were not able to report your earnings, or you reported them
late for reasons you could not control. If you had good cause, the amount you owe
may be less.
The reason for this overpayment is:
You can pay back this amount in many ways, as listed on this page and the next page.
You also can ask your case manager or eligibility worker how we determined your
overpayment. Please contact your case manager or eligibility worker if you have any
questions.
Required Recovery Methods
You may wish to use the Voluntary Repayment Plan listed on the next page. If you do not
wish to use the Voluntary Repayment Plan, or we cannot agree with your Voluntary
Repayment Plan, we must use the Required Recovery Method.
1. In all programs, Oregon State law 2. In all programs, Oregon State law says we can
says you must pay back the
take court action. Oregon law also says we can
overpayment from any resource
collect from money that other state agencies
you have. This means cash, savings
may owe you. For example, we can take Oregon
accounts, or any other source of
tax refunds and elderly rental assistance. If we
money.
are charged any collection fees or costs, we will
credit your account for the amount we collect
that is left after the fee.
DHS 0284S (01/05)
Replaces and Recycle SDS 0284S
Client Name:
3. If you are receiving General Assistance
benefits, we will lower your grant by
10 percent of your total needs or your
total grant amount, whichever is less.
This is in addition to 1 and 2 of this
section.
Date of Planned Action:
.
4. In the Oregon Supplemental Income
Program, we will lower your grant by
10 percent of your total needs or your
total grant amount, whichever is less.
This is in addition to #1 and #2 in this
section. Date of planned action:
.
5. If you no longer get services or other
benefits, you must call or write to:
Signature of Agency Representative
DHS Overpayment Recovery Unit
P.O. Box 14150
Salem, OR 97309
(503) 373-1872 or
Toll Free: 1-800-273-0548
will help you arrange a repayment plan.
We may increase this overpayment
amount if we find additional cash,
medical, or service benefits you
received that you were not entitled to.
Oregon Administrative Rules:
461-195-0501, 461-195-0521, 461195-0541, 461-195-0551, and
.
Branch Office
PUBLIC ASSISTANCE/FOOD STAMP REPAYMENT AGREEMENT
We will use the required recovery methods listed above and on the previous page. In
addition, you may choose one of the Voluntary Repayment Plans listed below:
My entire overpayment debt of $
is enclosed.
Enclosed is $
. I will pay the balance of my overpayment with monthly
payments of $
until paid in full (see payment schedule below.)
Your Signature
Date
Print Name
SSN:
DHS 0284S (01/05)
Replaces and Recycle SDS 0284S
If You Do Not Agree
You have the right to talk with a supervisor
if you do not agree with this overpayment.
You may ask for a meeting by contacting
your local branch office.
If this overpayment happened because you
did not report money from work, you may
claim “good cause”. Good cause means you
were not able to report your earnings, for
reasons you could not control. If you had
good cause, the amount you owe may be
less.
You have the right to ask for a hearing if
you do not agree with the over-payment.
Hearings are held before a hearing officer.
Some hearings are held by telephone.
At a meeting or hearing, you can explain
why you do not agree with the
overpayment. You can also have people
testify for you. You can have a lawyer or
someone else help you. We cannot pay the
costs of witnesses or a lawyer. You may get
free legal services through a legal aid office
or the local bar association.
Someone at your local branch office will help you fill out
the form.
In some cases, you do not have a right to a hearing on the
reason for, or amount of, this overpayment. They include:
! When you have already had a hearing on the same
issue.
! When you have signed legal papers saying you
received this overpayment.
! When a court has decided that you received this
overpayment.
! When you did not ask for a hearing within 45 days
from the date of any previous notice of this
overpayment.
! You can delay paying us back until the hearing decision
is made. To do this:
! You must let your branch office know, within 10 days
from the date of this notice, that you want a hearing;
and
! For cash and medical overpayments, you must fill out a
If you want a hearing, you must ask
DHS 0443 form within 15 days from the date of this
for one within 45 days from the
notice.
date of this notice. For cash and
you are getting benefits, you can have them lowered now
medical overpayment, your hearing If
to pay us back. If the hearing is in your favor, we will pay
request must be written on a
you back any money we collected.
DHS 0443 form, “Administrative
Hearing Request.”
Department of Human Services (DHS) will not discriminate against anyone. This
means DHS will help all who qualify. DHS will not deny help to anyone based on
age, race, color, national origin, sex, sexual orientation, religion, political beliefs or
disability. You can file a complaint if you think DHS discriminated against you
because of any of these reasons.
Distribution: Original - Client
Copy 1 - Overpayment Recovery
Copy 2 - Case Record
DHS 0284S (01/05)
Replaces and Recycle SDS 0284S