Form SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) De

Form Approved
OMB No. 0960-XXXX

SOCIAL SECURITY ADMINISTRATION

Financial Disclosure for Civil Monetary Penalty (CMP) Debt
We will use this form to obtain financial information relating to the
recovery of your CMP debt.

FOR SSA USE ONLY

Input Date
Please print your answers to the questions on this form as
completely as you can. We will help you fill out the form if you want. Amount of CMP $
If you are filling out this form for someone else, answer the
Violation:
questions as they apply to that person.
Title II

Title XVI

ACTION: _____________________________
Approved $________
Denied
A. Name of person who owes the Civil Monetary Penalty (CMP)

B. Social Security Number

YOUR FINANCIAL STATEMENT
Please answer all the questions as fully and completely 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



Papers showing you are receiving public
assistance



Your most recent Tax return



2 or 3 recent utility, medical, charge card, and
insurance bills




Checking Account Statements



Pay stubs

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 6.
1. A. Did you lend or give away any property or cash after
notification of the CMP?

Yes (Answer Part B)
No (Go to question 2)

B. Who received it, relationship (if any), description and value:

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

Yes (Answer Part B)
No (Go to question 3)

B. Describe property and sale price or amount of cash
received:
3. A. Are you now receiving cash public assistance?

B. Name or kind of public assistance:

Form SSA-640 (XX-2009)

Yes (Answer B and C)
No (Go to question 4)
C. Claim Number:

Page 1 of 7

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

AGE

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

Assets-Things You Have And Own
5. A. How much money do you and any person(s) listed in question 4 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

Text

PER MONTH

SAVINGS (Bank, Savings and Loan,
Credit Union)

$

$

CERTIFICATES OF DEPOSIT (CD)

$

$

INDIVIDUAL RETIREMENT ACCOUNT
(IRA)

$

$

MONEY OR MUTUAL FUNDS

$

$

BONDS, STOCKS

$

$

TRUST FUND

$

$

CHECKING ACCOUNT

$

$

OTHER (EXPLAIN)

$

$

$

$

TOTALS

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

Enter the "Per Month" total on
line (k) of question 9.

6. 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

Form SSA-640 (XX-2009)

YEAR,
MAKE/MODEL

PRESENT
VALUE

LOAN
BALANCE
(if any)

$

$

$

$

$

$

MAIN PURPOSE FOR USE

Page 2 of 7

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

DESCRIPTION

MARKET
VALUE

LOAN
BALANCE
(if any)

$

$

$

$

$

$

USAGE-INCOME
(rent etc.)

Monthly Household Income
If paid weekly, multiply by 4.33 (4 1/3) to figure monthly pay. If paid every 2 weeks, multiply by 2.166 (2 1/6) If
self-employed, enter 1/12 of net earnings. Enter monthly TAKE HOME amounts on line A of question 9 also.
7. A. Are you employed?

YES (Provide information below)

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

NO (Skip to B)
Monthly pay before
deduction (Gross)

$

Monthly TAKE HOME
pay (NET)
$
B. Is your spouse employed?

YES (Provide information below)

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

NO (Skip to C)
Monthly pay before
deduction (Gross)

$

Monthly TAKE HOME
pay (NET)
$
C. Is any other person listed in Question 4 employed?
NO (Go to Question 8)
YES
NAME(S):
Employer(s) name, address, and phone: (Write "self" if self-employed) Monthly pay before
deduction (Gross)

$

Monthly TAKE HOME
pay (NET)
$
8. A. Do you, your spouse or any dependent member of your household receive support or contributions from any
person or organization?
YES (Answer B)
NO (Go to question 9)
B. How much money is received each month?
(Show this amount on line (J) of question 9)

Form SSA-640 (XX-2009)

SOURCE
$

Page 3 of 7

9. BE SURE TO SHOW MONTHLY AMOUNTS BELOW - If received weekly or every 2 weeks, read the instruction
directly above #7.
INCOME FROM #7 AND #8
ABOVE AND OTHER INCOME
TO YOUR HOUSEHOLD
A. TAKE HOME Pay (Net)
(From #7, A, B, C above)

YOURS

$

SPOUSES

OTHER
HOUSEHOLD
MEMBERS

SSA USE
ONLY

$

B. Social Security Benefits
C. Supplemental Security
Income (SSI)
D. Pension(s) (specify type)
(VA, Military, Civil Service,
Railroad, etc.)
E. Public Assistance
F. Food Stamps (Show full face
value of stamps received)
G. Income from real estate
(rent, etc.) (From question 6B)
H. Room
H. Room
and/or
and/or
Board
Board
Payments
Payments
(Explain
(Explain
in remarks
in remarks
below)
below)
I. Child Support/Alimony
J. Other Support (From #8(B)
above)
K. Income From Assets (From
question 5)
L. Other (From any source,
explain below)
TOTALS
REMARKS

Form SSA-640 (XX-2009)

$

$

$
GRAND TOTAL
(Add 3 total blocks above)

$

Page 4 of 7

MONTHLY HOUSEHOLD EXPENSES
If the expense is paid weekly or every 2 weeks, read the instruction on Page 3. 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).
$ PER
MONTH

10.

A. Rent or Mortgage (If mortgage payment includes property or other local taxes,
insurance, etc. DO NOT list again below.

$

B. Food (Groceries (include the value of food stamps) and food at restaurants, work, etc.)
C. Utilities (Gas, electric, telephone)
D. Other Heating/Cooking Fuel (Oil, propane, coal, wood, etc.)
E. Clothing
F. Credit Card Payments (show minimum monthly payment allowed)
G. Property Tax (State and local)
H. Other taxes or fees related to your home (trash collection, water-sewer fees)
I. Insurance (Life, health, fire, homeowner, renter, car, and any other casualty or
liability policies)
J. Medical-Dental (After amount, if any, paid by insurance)
K. Car operation and maintenance (Show any car loan payment in (N) below))
L. Other transportation
M. Church-charity cash donations

N. Loan, credit, lay-away payments (If payment amount is optional, show
minimum)

O. Support to someone NOT in household (Show name, age, relationship (if any)
and address)

P. Any expense not shown above (Specify)

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

Form SSA-640 (XX-2009)

Page 5 of 7

SSA
USE
ONLY

INCOME AND EXPENSES COMPARISON
11. A. Monthly income
(Write the amount here from the "Grand Total" on #9).
B. Monthly expenses
(Write the amount here from the "Total" on # 10)

$
$

C. Adjusted Household Expenses

+ $25

D. Adjusted Monthly Expenses (Add B and C)

$

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

FOR SSA USE ONLY
INC. EXCEEDS $
ADJ EXPENSE +
INC. LESS THAN $
ADJ EXPENSE +

FINANCIAL EXPECTATION AND FUNDS AVAILABILITY
13. 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).

YES (Explain in Remarks
space below)
NO

B. If there is an amount of cash on hand or in checking accounts shown in
item 5A, is it being held for a special purpose?

NO amount on hand
NO (Money available for
any use)
YES (Explain in Remarks
space below)

C. Is there any reason you CANNOT convert to cash the "Balance or Value"
of any financial asset shown in item 5B?

YES (Explain in Remarks
space below)
NO

D. Is there any reason you CANNOT SELL or otherwise convert to cash any
of the assets shown in items 6A and B?

YES (Explain in Remarks
space below)
NO

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

Form SSA-640 (XX-2009)

Page 6 of 7

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 PERSON OWING CMP
PRINTED NAME (First name, middle initial, last name) (Write in ink)

DATE (Month, Day, Year)

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

HOME TELEPHONE NUMBER (Include
area code)

SIGN HERE

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

CITY AND STATE

ZIP CODE

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

Witnesses are required ONLY if this statement has been signed by mark(X) above. If signed by mark(X), two
witnesses to the signing who know the individual must sign below, giving their full addresses.
SIGNATURE OF WITNESS

SIGNATURE OF WITNESS

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

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

Privacy Act Statement - Collection and Use of Personal Information
Sections 205(a), 1129(c)(3) and 1129(e)(1), of the Social Security Act, authorize us to collect this information. The
information is needed to make a determination regarding the payment of the Civil Monetary Penalty (CMP). Your response is
voluntary. However, failure to provide all or part of the requested information could prevent an accurate and timely decision
on your request.
We rarely use the information provided on this form for any other purpose other than for the reasons explained above.
However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but are not limited to the
following:
(1) To a Federal, State or local agency for law enforcement purposes concerning a violation of law pertaining to SSA programs
and operations.
(2) To the Department of Justice in connection with requests for legal advice and in connection with actual or potential
criminal prosecutions or civil litigation pertaining to an investigation of SSA programs and operations conducted by the Office
of the Inspector General.
(3) To a Federal or State grand jury, a Federal or State court, administrative tribunal, opposing counsel, or witnesses in the
course of civil, criminal, or administrative proceedings pertaining to an investigation of SSA programs and operations
conducted by the Office of the Inspector General.
We may also use the information you provide in computer matching programs. Matching programs compare our records with
records kept by other Federal, State or local government agencies. Information from these matching programs can be used to
establish or verify a person's eligibility for Federally funded and administered benefit programs and for repayment of payments
or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Records Notice 60-0265. The notice, additional
information regarding this form, and information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security office.
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 2 hours to read the instructions, gather
the facts, and answer the questions. SEND 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 only comments relating to our time estimate to this address, not the completed form.

Form SSA-640 (XX-2009)

Page 7 of 7

Instructions for Completing the Form SSA-640 – Financial Disclosure for a
Civil Monetary Penalty (CMP) Debt

When to Use this Form
This form is used to collect financial information from an individual who owes a CMP debt.
SSA will use the information collected in making decisions concerning repayment of the CMP.
EVIDENCE: When you file a request about how you will repay the CMP debt, you need to
present any papers you have verifying your financial statements. This would include items such
as current bank statements, utility bills, pay stubs, credit card payments, loan payments, etc. If
you do not have these records immediately available, do not delay filing this form. You have up
to 30 days from filing your request concerning repayment of the CMP to supply them.
The following section explains how to complete the SSA-640. The SSA-640 along with
supporting financial documentation should be either returned to the address that is on the return
envelope that was included with this form. If you have further questions about the SSA-640,
you may contact the SSA office that gave you this form.
HOW TO COMPLETE THE SSA-640 FORM:
A. Print the name of the person who owes the CMP debt
B. Enter the Social Security Number of the person who owes the CMP debt.
YOUR FINANCIAL STATEMENT
1. – 3. Answer in all cases, filling in the narrative portions.
Members of Household
4. List your dependents who live with you regardless of relation.
Assets-Thing You Have and Own
5. List for yourself and anyone listed in #4. Be sure to list both the balances and the income
earned each month.
6. Be sure to list the vehicles and real property for both yourself and your household members.
Monthly Household Income
7. through 9. Read each question carefully, filling in the blanks with incomes for you, your
spouse, and all other individuals listed in #4. Make sure to list on a monthly basis. The note
above question #5 tells you how to handle weekly, biweekly and yearly amounts.

Monthly Household Expenses
10. List the total household expenses, again converting to monthly figures.
Income and Expenses Comparison
11. through 13. Complete as indicated.
Remarks: Use to continue answers to prior questions. Make sure to put the question number, to
which you are referring, first. If you need more space, continue on any blank sheet of paper.
Signature Of Person Owing CMP
Please be sure to sign and date, list your mailing address and the phone number(s) where we may
reach you.
Where to Send the Form
After you have completed and signed this form, fold it in thirds, insert it in the return envelope
that came with the form and mail it. Use the return envelope provided so that this form goes to
the SSA office that is handling your request.