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

Form Approved
OMB No. 0960-0776

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
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 If you are filling out this form for
someone else, answer the questions as they apply to that person.

A.

Penalty (CMP)

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

• 2 or 3 recent utility, medical, charge card, and
insurance bills
• Checking Account Statements

• Papers showing you are receiving public
assistance

• Similar documents for your spouse or dependent
family members

• Your most recent Tax return

• Pay stubs

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?

0

Yes
(Answer Part B)

0

Yes
(Answer Part B)

o

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?

0

No
(Go to question 3)

0

No
(Go to question 4)

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

3.

0

A. Are you now receiving cash public assistance?

C. Claim Number:

B. Name or kind of public assistance:

Form SSA-640 (01-2010)

Yes
(Answer Part B and C)

Page 1

Members of Household
4.

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 I
person is dependent on you)
•

AGE

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?

1$

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

PER MONTH

SAVINGS (Bank, Savings and Loan,
Credit Union)

$

CERTIFICATES OF DEPOSIT (CD)

$

$
$

INDIVIDUAL RETIREMENT ACCOUNT
(IRA)

$

$

MONEY OR MUTUAL FUNDS

$

$

$

$

TRUST FUND

$

$

CHECKING ACCOUNT

$

$

OTHER (EXPLAIN)

$

$

$1

$1

TOTALS

6.

BALANCE OR
VALUE

OWNER

I

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.

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 (01-2010)

LOAN
BALANCE (if
any)

PRESENT
VALUE

YEAR, MAKEI
MODEL

$

$

$

$

$

$

Page 2

MAIN PURPOSE FOR USE

6.

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

LOAN
BALANCE (if
any)

MARKET
VALUE

DESCRIPTION

$

$

$

$

$

$

USAGE-INCOME (rent, etc.)

Monthly Household Income
If paid weekly, multiply by 4.33 (41/3) to figure monthly pay. If paid every 2 weeks, multiply by 2.166 (21/6) 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?

DYes
(Provide information below)

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

B. Is your spouse employed?

Monthly pay before
deduction (Gross)

$

Monthly TAKE HOME
pay (NET)

$

DYes
(Provide information below)

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

8.

$

Monthly TAKE HOME
pay (NET)

$

D

A. Do you, your spouse or any dependent member of

D

your household receive support or contributions from
any person or organization?

$

Form SSA-640 (01-2010)

Page 3

No
(Go to question 8)

Monthly pay before
deduction (Gross)

$

Monthly TAKE HOME
pay (NET)

$

Yes
(Answer B)

D

Source

B. How much money is received each month?
(Show this amount on line (J) of question 9)

No
(Skip to C)

D

Monthly pay before
deduction (Gross)

C. Is any other person listed in Question 4 employed?
NAMES:
Yes
D
Employer's name, address, and phone: (Write "self' if self-employed)

No
(Skip to B)

D

No
(Go to question 9)

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

YOURS

HOME Pay (Net) (From #7,
B, C above)

OTHER
HOUSEHOLD
MEMBERS

SPOUSES

D

D

$

B. Social Security Benefits

D

D

C. Supplemental Security Income
(SSI)

D

D

D. Pension(s) (specify type) (VA,
Military, Civil Service, Railroad, etc.)

D

D

D

D

tamps (ShOW full face
of stamps received)

$

D

G. Income from real estate (rent,
(From question 6B)

D

D

H. Room and/or Board Payments
(Explain in remarks below)

D

D

I. Child Support/Alimony

D

D

D

D

D

D

D

D

Other Support (From #8{B) above)

$

$

D
$

Total

3 total blocks above)

Form SSA-640 (01-2010)

4

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

amount if the

of CREDIT CARD EXPENSE SHOWN ON LINE

AXf1iAm!A

10.

$PER
MONTH
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)

Medical-Dental (after amount, if any, paid by insurance)

Car operation and maintenance (show any car loan payment in (N) below)

L. Other transportation
M. Church-charity cash donations
M. Church-charity cash donations (cont.)
M. Church-charity cash donations (cont.)

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

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

. Any expense not shown above (SpeCify)

TOTAL
L..-...,.-.,..-_ __
EXPENSE REMARKS (Also explain any unusual or very large expenses, such as medical, college, etc.)

Form SSA-640 (01-2010)

Page 5

INCOME AND EXPENSES COMPARISON

11.

Monthly income
Write the amount here from the "Grand Total" on #9
B. Monthly expenses
Write the amount here from the "Total" on #10

$

$
+$25

$
12. If your expenses (D) are more than your income (A),

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

YES (Explain in
Remarks
space below)

o Amount
NO
q Money
NO
on Hand

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

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

D

D

0

NO

0

Available
For any use)

YES (Explain in
Remarks
space below)
YES (Explain in
Remarks
space below)

o

YES
(Explain in
Remarks
space
below)
NO

o 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 (01-2010)

Page 6

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)

[SIGN HERE

HOME TELEPHONE NUMBER (Include area
code)

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

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

iCITY AND STATE

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

ZIP CODE

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· C lection and Use of Personal Information
Sections 205(a), 1129(c)(3 and 1129(e)(1), of the Social S urity Act, authorize us to collectth' information. The
information is needed to ake a determination regarding e payment of the Civil Monetary P alty (CMP). Your response is
accurate and timely decision
voluntary. However, fail e to provide all or part of the r uested information could prevent
on your request.
We rarely use the i rmation provided on this fo
for any other purpose other than f the reasons explained above.
However, we rna use it for the administration a integrity of Social Security progra s. We may also disclose informati
another person r to another agency in accord nce with approved routine uses, w ch include but are not limited to the
following:
(1) To a Fe eral, State or local agency fo lawenfor

See revised
Privacy Act
Statement below

a violation of law pertaining to SS

and oper Ions.
(2) To t
Department of Justice in
nection with
.
in connection with actual or pote ial
programs and operations conducted b the Office
crimin prosecutions or civillitigati pertaining to an investigation of S
of th Inspector General.
(3) 0 a Federal or State grand' ry, a Federal or State court, admin' ative tribunal, OPPOSing counsel, or witn ses in the
rse of civil, criminal, or ad Inistrative proceedings pertaining to n investigation of SSA programs and oper. tions
nducted by the Office of t Inspector General.
We may also use the inf rmation you provide in computer m hing programs. Matching programs com par our records with
records kept by other deral, State or local government a ncies. Information from these matching progr ms can be used to
rson's eligibility for Federally funde and administered benefit programs and for re yment of payments
establish or verify a
or delinquent deb under these programs.
A complete list f routine uses for this information is vailable in Systems of Records Notice 60-0265. he notice, additional
information r arding this form, and information re arding our programs and systems, are available 0 -line at
www.socia ecurity.gov or at your local Social S unty office.
Paperwork Reduction Ac tatement -This information c Ie .
.
U.S.C. § 3507, as am ded by
section 2 of the Paperwo Reduction Act of 1995. You d no See revised Paperwork
less we display a v .
Office of Management a CI Budget control number. We stirn Reduction Act Statement ead the instructio ,gather
the facts, and answer e questions. SEND THE CO
LETE b I
L SECURITY 0
ICE. The office
is listed under U. S. overnment agenCies in yo teleph e ow.
ial Security a ·800·772·1213 (TTY
rtlme estimate above to: S A, 6401 Security Blvd., B imore, MD
1-800.325-0778). Y u may send comments on
21235-6401. Sen only comments relating to ou time estimate to this address, not the completed form.

Form SSA-640 (01-2010)

Page 7

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

When to Use this Form
This fonn is used to collect financial information from an individual who owes a CMP debt. SSA will use the
infonnation collected in making decisions concerning repayment ofthe 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 fonn. 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- Thin~ 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 HousehQld IncQme
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 eMP

Please be sure to sign and date, list your mailing address and the phone number(s) where we may reach you.

Where tQ Send the F onn

After you have completed and signed this fonn, fold it in thirds, insert it in the return envelope that came with the fonn

and mail it. Use the return envelope provided so that this fonn goes to the SSA office that is handling your request.

Form SSA-640 (01-2010)

Page 8

SSA will insert the following revised PRA Statement 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 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.
You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
reprinting:

Privacy Act Statement
Collection and Use of Personal Information
Section 204(a) (42 U.S.C. § 404(a)) of the Social Security Act, as amended, authorizes us to
collect the information on this form. We will use the information you provide to obtain financial
information relating to the recovery of your Civil Monetary Penalty (CMP) debt.
Your response is voluntary. However, failing to provide us with all or part of the information
could affect our ability to determine your eligibility for future Social Security benefits.
We rarely use the information you provide for any purpose other than for recovering your CMP
debt. In accordance with 5 U.S.C. § 552a(b) of the Privacy Act, however, we may disclose the
information provided on this form in accordance with approved routine uses, which include but
are not limited to the following:
1. To enable a third party or an agency to assist Social Security in recovering program debt;
2. To comply with Federal laws requiring the release of information from Social Security records
(e.g., to the Government Accountability Office and Department of Veterans' Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at
the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Computer
matching programs compare our records with those of other Federal, State, or local government
agencies. We can use information from these matching programs to establish or verify a person's
eligibility for federally-funded or 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 our System of Records Notice
entitled, Recovery of Overpayments, Accounting and Reporting/ Debt Management System
(ROAR/DMS) 60-0094. This notice, additional information regarding this form, and information
regarding our programs and systems, are available on-line at http://www.socialsecurity.gov or at
your local Social Security office.