Form SSA-632-BK Request for Waiver of Overpayment Recovery or Change in

SOCIAL SECURITY ADMINISTRATION

OMB
Form NO.
~pproved
0960-0037

Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate

We will use your answers on this form to decide if we can waive
collection of the overpayment or change the amount you must pay us
back each month. If we can't waive collection, we may use this form
to decide how you should repay the money.

*;
,,"

Please answer the questions on this form as completely as you can.
We will help you fill out the form if you want. If you are filling out
this form for someone else, answer the questions as they apply to that
person.

1.

A. Name of person on whose record
the overpayment occurred:

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B. Social Security Number

C. Name of overpaid person(s) making this request and hislher Social Security Number(s):

2.

Check any of the following that apply. (Also, Fill in the dollar amount in B, C, or D.)

A; [JI The overpayment was not my fault and I cannot afford to
other reasons.
B.

the money back and/or it is unfair for some

I cannot afford to use all of my monthly benefit to pay back the overpayment. However I can afford
to have $
withheld each month

C. [JI Iam no longer receiving Supplement Security Income (SSI) payments. I want to pay back $
each month instead of paying all of the money at once.
D.

I am receiving SSI payments. I want to pay back $
my total income.

Form SSA-632-BK(12-2002) ef (08-2008)

Page 1

4.

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;%-.ii;$,

each month instead of paying 10% of

SECTION I-INFORMATION ABOUT RECEIVING THE OVERPAYMENT

3.

A. Did you, as representativepayee, receive the overpaid benefits to use for the beneficiary?
Yes

CJ No (Skip to Question 4)

B. Name and address of the beneficiary

C. How were the overpaid benefits used?

4.

If we are asking you to repay someone else's overpayment:
A. Was the overpaid person living with you when helshe was overpaid?

B. Did you receive any of the overpaid money?

Yes

No

Yes

NO

C. Explain what you know about the overpayment AND why it was not your fault.

5,

Why did you think you were due the overpaid money and why do you think you were not at fault in causing the
overpayment or accepting the money?

6.

A. Did you tell us about the change or event that made you overpaid?
If no, why didn't you tell us?

a yes

NO

B. If yes, how, when and where did you tell us? If you told us by phone or in person, who did you talk
with and what was said?

C. If you did not hear from us after your report, andlor your benefits did not change, did you
contact us again?

7.

A. Have we ever overpaid you before?

C]Yes

No

Yes

No

If yes, on what Social Security number?
B. Why were you overpaid before? If the reason is similar to why you are overpaid now, explain what you did
to try to prevent the present overpayment.

Form SSA-632-BK (12-2002) ef (08-2000)

Page 2

FOR SSA USE ONLY

SECTION II-YOUR FINANCIAL STATEMENT
rate at which we asked you to repay it. Please answer all questions as fully and as carefully as possible. We may ask to
see some documents to support your statements, so you should have them with you when you visit our office.
EXAMPLES ARE:
Current Rent or Mortgage Books
Savings Passbooks
Pay Stubs
Your most recent Tax Return

2 or 3 recent utility. medical, charge card,
and insurance bills
Cancelled checks
Similar documents for your spouse or
dependent family members

Please write only whole dollar amounts-Round any cents to the nearest dollar. If you need more space for answers, use the
"Remarks" section at the bottom of page 7.

9.

A. Do you now have any of the overpaid checks or money in your
possession (or in a savings or other type of account)?
B. Did you have any of the overpaid checks or money in your
possession (or in a savings or other type of account) at
the time you received the overpayment notice?

10.

Return this amount to SSA
No
Yes
Amount:$
Answer Question 10.
No

Explain why y w believe you should not have to return this amount.

ANSWER 11 AND 12 ONLY IF THE OVERPAYMENT IS SUPPLEMENTAL SECURITY INCOME
PAYMENTS (SSI). IF NOT. SKIP TO 13.

11.

12.

A. Did you lend or give away any property or cash after notification
of the overpayment?
B. Who received it, relationship (if any), description and value:

Yes (Answer Part B)

A. Did you receive or sell any property or receive any cash (other
than earnings) after notification of this overpayment?

Yes (Answer Part B)

B. Describe property and sale price or amount of cash received:

13.

A. Are you now receiving cash public assistance such as
Supplemental Security Income (SSI) payments?

No (Go to question 12.)

No (Go to Question 13.)

Yes

(Answer B and C and
See note below)

No
B. Name or kind of public assistance

C. Claim Number

IMPORTANT: If you answered YES" to question 13, DO NOT answer any more questions on this form.
Go to page 8, sign and date the form, and give your address and phone number(s). Bring or mail any papers that show you
receive public assistance to your local Social Security office as soon as possible.
Form SSA-632-BK (12-2002) ef (08-2006)

Page 3

Members Of Household

14.

List any person (child, parent, friend, etc.) who depends on you for support AND who lives with you.
NAME

RELATIONSHIP (If none, explain why the person is dependent on you)

AGE

Assets-Things You Have And Own
A. How much money do you and any person(s) listed in question 14 above have
as cash on hand,in a checking account, or otherwise readily available?
B. Does your name, or that of any other member of your household appear,
either alone or with any other person, on any of the following?
TYPE OF ASSET

OWNER

BALANCE
OR VALUE

SHOW THE INCOME (Interest, dividends)
EARNED EACH MONTH. (If none
explain in spaces below) If paid
quarterly, divide by 3.

PER MONTH

SAVINGS (Bank, Savings and
Loan, Credit Union)

$

$

$

$

CERTIFICATES OF DEPOSIT (CD)

$

$

IS

I$

MONEY OR MUTUAL FUNDS

$

$

BONDS, STOCKS

$

$

TRUST FUND

$

$

INDIVIDUAL RETIREMENT ACCOUNT (IRA)

I

I

CHECKING ACCOUNT

16.

OTHER (EXPLAIN)

I

I

TOTALS +I$

Enter the "Per Month total on line
(k) of question 19.

$

A. If you or a member of your household own a car, (other than the family vehicle), van, truck,

camper, motorcycle, or any other vehicle or a boat, list below.
OWNER

YEAR, MAKEIMODEL

PRESENT
VALUE

LOAN BALANCE
(if any)

$

$

$

$

$

$

MAIN PURPOSE FOR USE

B. If you or a member of your household own any real estate (buildings or land), OTHER than where
you live, or own or have an interest in, any business, property, or valuables, describe below.
OWNER

Form SSA-632-BK (12-2002) ef (08-2006)

DESCRIPTION

Page 4

MARKET
VALUE

LOAN BALANCE
(if any)

$

$

$

$

$

$

$

$

USAGE-INCOME
(rent etc.)

Monthly Household Income
~

~

If paid weekly, multiply by 4.33 (4 113) to figure monthly pay. If paid every 2 weeks, multiply by 2.166 (2 116) If
selfemployed, enter 1/12 of net earnings. Enter monthly TAKE HOME amounts on line A of question 19 also.

17.

A. Are you employed?

Monthly pay before
deduction (Gross)
Monthly TAKE-HOME

Employer name, address, and phone: (Write "self" if self-employed)

B. Is your spouse employed?

NO (Skip to B)

YES (Provide information below)

NO (Skip to C)

YES (Provide information below)

Employer(s) name, address, and phone: (Write "self" if self-employed)

Monthly pay before
deduction (Gross)
Monthly TAKE-HOME
Pay (NET)

C. Is any other person listed
in Question 14 employed?

1
G
O: : :

$
$

Name(s)
to Question 18)

Employer(s) name, address, and phone: (Write "self" if self-employed)

18.

$

,1

A. Do you, your spouse or any dependent member of your household
receive suDDort or contributions from anv Derson or oraanization?

B. How much money is received each month?
$
(Show this amount on line (J) of auestion 19)

Monthly pay before
deduction (Gross)
Monthly TAKE-HOME

YES (Answer B)

o:

1,
(Go to question 19)

SOURCE

-

BE SURE TO SHOW MONTHLY AMOUNTS BELOW If received weeklv or everv 2 weeks. read the instruction at the too of this oaae.

B. Social Security Benefits
C. Supplemental Security Income (SSI)

I

E. Public Assistance TYPE
(Other than SSI)
F. Food Stamps (Show full face
value of stamps received)

l l ~ d3
d total blocks above)

Form SSA-632-BK (12-2002) ef (08-2006)

Page 5

I

MONTHLY HOUSEHOLD EXPENSES
If the expense is paid weekly or every 2 weeks, read the instruction at top of Page 5. Do NOT list an expense that is
withheld from income (Such as Medical Insurance). Only take home pay is used to figure income.
Show "CC" as the expense amount if the expense (such as clothing)
is part of CREDIT CARD EXPENSE SHOWN ON LINE (F).

20.

SSA
USE

$ PER MONTH

A. Rent or Mortgage (If mortgage payment includes property or other local taxes,

E. Clothing
F. Credit Card Payments (show minimum monthly payment allowed)

- ..,- ,
..t , , -.

J. Medical-Dental (After amount, if any, paid by insurance)

- -

K. Car operation and maintenance(Show any car loan payment in (N) below)

EXPENSE REMARKS Also explain any unusual or very
large expenses, such as medical, college, etc.)

Form SSA-632-BK (12-2002) ef (08-2006)

Page 6

,

TOTAL

$

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5 a

INCOME AND EXPENSES COMPARISON

21.

,,

A. Monthly income
(Write the amount here from the "Grand Total" of #19.

$

B. Monthly Expenses
Write the amount here from the "Total" of #20.

$

P

22.

C. Adjusted Household Expenses

b

D. Adjusted Monthly Expenses (Add (B) and (C))

b$

If your expenses (D) are more than your income (A),
explain how you are paying your bills.

+

$25

FOR SSA USE ONLY
INC. EXCEEDS
ADJ EXPENSE

$

INC LESS THAN
ADJ EXPENSE

$

+

-

FINANCIAL EXPECTATION AND FUNDS AVAILABILITY

23. A.

Do you, your spouse or any dependent member of your household expect your or
their financial situation to change (for the better or worse) in the next 6 months?
(For example: a tax refund, pay raise or full repayment of a current bill for the
better-major house repairs for the worse).

B. If there is an amount of cash on hand or in checking accounts
shown in item 15A, is it being held for a special purpose?

Fin

YES (Explain on
below)

No amount on hand
NO (Money available for any use)
YES (Explain on line below)

C. Is there any reason you CANNOT convert to cash the "Balance or Value"
of any financial asset shown in item 15B.

D. Is there any reason you CANNOT SELL or otherwise convert to cash
any of the assets shown in items 16A and B?

REMARKS SPACE -

CI

YES (Explain on line
below)
NO

YES (Explain on line
below)
NO

If you are continuing an answer to a question, please write the number (and letter,
if any) of the question first.

(MORE SPACE ON NEXT PAGE)

Form SSA-632-BK (12-2002) ef (08-2006)

Page 7

(REMARKS SPACE (Continued)

PENALTY CLAUSE, CERTIFICATION AND PRIVACY ACT STATEMENT
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly
gives a false or misleading statement about a material fact In this information, or causes someone else to do so,
commits a crime and may be sent to prison, or may face other penalties, or both.

.

SIGNATURE OF OVERPAID PERSON OR REPRESENTATIVE PAYEE
DATE (Month, Day,Year)

SIGNATURE (First name, middle initial, last name) (Write ink)

HERE

HOME TELEPHONE NUMBER (Include area code)

1

(

-

WORK TELEPHONE NUMBER IF WE MAY CALL YOU AT
WORK (Include area code)

1

(

-

MAILING ADDRESS (Number and street. Apt. No.. P.O. Box, or Rural Route)
CITY AND STATE

ENTER NAME OF COUNTY (IF ANY) IN WHICH YOU
NOW LIVE

ZIP CODE

-

Witnesses are required ONLY if this statement has been sinned bv mark (XI above. If sinned by mark (XI,
. .. two
witnesses to the signing who know the individual must sign below, giving heir full addresses:
SIGNATURE OF WITNESS

SIGNATURE OF WITNESS

ADDRESS (Number and street. City, State, and ZIP Code)

About the Privacy Act
The Social Security Act (Sections 204. 1631(b), and 1870) and
the Federal Coal Mine Health and Safety Act of 1969 allow us to
collect the facts on this form. This form is voluntary. However, if
you do not give us the facts we ask for, we may not be able to
approve your waiver request. If we cannot collect the
overpayment, we may ask the Justice Department to collect it.

I

ADDRESS (Number and street, City, State, and ZIP Code)

Explanations about these and other reasons why information you
provide us may be used or given out are available in Social
Security offices. If you want to learn more about this, contact any
Social Security office,

cL.

Clev;scL PC&, 4&
- This information

Paperwork Reduction Act Statement

Sometimes the law requires us to give out the facts on this form
without your consent. We must give these facts to another person
or government agency if Federal law requires that we do so or to
do the research and audits needed to monitor and improve the
programs we manage.
We may also give these facts to the Justice Department to
investigate and prosecute violations of the Social Security Act or
we may use the facts in computer matching programs. Matching
programs compare our records with those of other Federal, State,
or local government agencies. All the Agencies may use matching
programs to find or prove that a person qualifies for benefits paid
for or managed by the Federal government. Another use is to
identify and collect overpayments or to collect overdue loans
under these benefits programs.

Form SSA-632-BK (12-2002) ef (08-2006)

Page 8

mate to fhis a

Thefollowing revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 1-2
hours to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send & comments relating to our time estimate to this
address, not the completedform.