Form SSA-2032-BK Request for Waiver of special veterans Benefit (SVB) Ove

Form Approved
OMB No. 0960-0698

SOCIAL SECURITY ADMINISTRATION

Request for Waiver of Special Veterans Benefits (SVB) 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.
If you need more room for responses, use “REMARKS”
on page 13.

1.

FOR SSA USE ONLY
Input Date
Waiver Approval
Denial
Amt of O/P (Show in U.S. $)

Period (Dates) of O/P
MM/YYYY to MM/YYYY

Social Security Number

Name of Beneficiary

-

Name of Representative Payee (if applicable)

-

Social Security Number

-

-

If representative payee is requesting waiver or change in repayment rate, answer
1.A. and 1.B. and continue:
A. Were all or some of the overpaid SVB payments received used for the
beneficiary?
Yes
If yes, answer B. below.
No
If no, skip to Question 2.
Address of the beneficiary

B. How were the overpaid benefits used?

Form SSA-2032-BK

(3-2007)

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2.

If you are requesting waiver of the overpayment, please check block A. if it
applies to you:
A.

The SVB overpayment was not my fault and I cannot afford to pay the money
back and/or it is unfair to make me pay the money back for some other reason.
(Explain in “REMARKS” on page 13.)

If you are currently receiving SVB, please check block B. if it applies to you:
B.

I am receiving SVB, but cannot afford to have the amount of my monthly
benefit (or an amount equal to 10% of the maximum SVB monthly payment
amount, whichever is less) withheld from my SVB to pay back the overpaid
benefits I received. Instead, I want $________ (cannot be less than $1)
withheld each month from my SVB to pay back the overpayment.

If you are no longer receiving SVB, check block C. if it applies to you:
C.

I want to pay back $_____________ (cannot be less than $10) each month
instead of repaying the SVB overpayment at once.

SECTION I - INFORMATION ABOUT RECEIVING THE OVERPAYMENT

3.

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?

4.

A. Did you tell us about the change or event that made you overpaid?
Yes
If yes, complete 4.B. and, if applicable, 4.C. below.
No
If no, why didn’t you tell us?

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

Form SSA-2032-BK

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C. If you did not hear from us after your report, and/or the amount or payment of
your SVB did not change, did you contact us again?
Yes
If yes, what were you told would happen?
No

5.

A. Have we ever overpaid you before?
Yes
If yes, complete B. and C. below
No
If no, skip to Question 6.
B. If yes, on what Social Security number were you overpaid?

C. 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.

SECTION II - YOUR FINANCIAL STATEMENT

You must complete this section if you are asking us either to waive the collection of the
overpayment or to change the 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, or we may ask
you to send them to us.
Examples of documents 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
You can express amounts in local currency. If U.S. currency is shown, show whole
dollar amounts only – round any cents to the nearest dollar.

Form SSA-2032-BK

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6.

A. Do you now have any of the overpaid benefits in your possession (or in a
savings or other type of account)?
Yes
Amount: _______ Please contact VARO or SSA personnel
as shown in “IMPORTANT” below to
return these funds to SSA.
No
B. Did you have any of the overpaid benefits in your possession (or in a savings or
other type of account) when you received the overpayment notice?
Yes
Amount ________ Please complete Question 7 below.
No

7.

8.

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

A. Are you now receiving U.S. Federal, state or local cash public assistance such
as Supplemental Security Income (SSI) payments?
Yes
If yes, answer B. and C. See “IMPORTANT” below.
No
B. Name or kind of public assistance

C. Claim number

IMPORTANT: If you answered “Yes” to Question 8, DO NOT answer any more questions on
this form. Go to the spaces provided on page 13 at the end of the form for signature and date.
Sign and date the form, and provide your address and a telephone number. Bring or mail this
form (and any papers that show you receive U.S. Federal, state or local public assistance, if
this is the case) to your local Social Security office or to the U.S. Department of Veterans
Affairs Regional Office, 1130 Roxas Blvd., 0930 Manila (Ermita) as soon as possible.

U.S. Embassy, SSA, 1201 Roxas Blvd. Ermita 0930 Manila

Form SSA-2032-BK

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MEMBERS OF HOUSEHOLD – DO NOT Complete if Answer to 8.A. was “Yes”
9.

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

NAME

AGE

RELATIONSHIP
(If none, say why the person is your dependent)

ASSETS - THINGS YOU HAVE AND OWN – DO NOT Complete if Answer to 8.A.
was “Yes”
10.

A. How much money do you and any person(s) listed in Question 9 above have as
cash on hand, in a checking account, or otherwise readily available?

Amount:

B.

If there is an amount of cash on hand or in checking accounts shown in
Question 10.A., is it being held for a special purpose?
No amount on hand
No (Money available for any use.)
Yes (Explain on line below.)

Form SSA-2032-BK (3-2007)

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C. 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.

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

D. Is there any reason you CANNOT convert to cash the “Balance or Value” of
any financial asset shown in Question 10.C.?
Yes
If yes, explain on line below.
No

Form SSA-2032-BK (3-2007)

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11.

A. If you or a member of your household owns a car, van, truck, camper,
motorcycle or any other vehicle or a boat, (other than a vehicle used for family or
work transportation) list below.
LOAN
MAIN
YEAR,
PRESENT BALANCE PURPOSE
MAKE/MODEL VALUE
(if any)
FOR USE

OWNER

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

DESCRIPTION

MARKET
VALUE

LOAN
BALANCE
(if any)

USAGEINCOME
(rent, etc.)

C. Is there any reason you CANNOT SELL or otherwise convert to cash any of
the assets shown in Question 11.A. and 11.B.?
Yes
If yes, explain on line below.
No

Form SSA-2032-BK

(3-2007)

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MONTHLY HOUSEHOLD INCOME
BE SURE TO SHOW MONTHLY AMOUNTS BELOW. 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. Also, enter monthly TAKE HOME amounts on
line A of Question 14.
12. A. Are you employed?
Yes
If yes, provide information below.
No
If no, skip to 12.B.
Employer Name
Employer Address
Employer Telephone Number
If self-employed write “Self”
Monthly pay before any deduction: (Gross)
Monthly TAKE HOME pay (Net)
B. Is your spouse employed?
Yes
If yes, provide information below.
No
If no, skip to 12.C.
Employer Name
Employer Address
Employer Telephone Number
If self-employed write “Self”
Monthly pay before any deduction: (Gross)
Monthly TAKE HOME pay (Net)
C. Is any other person listed in Question 9 above employed?
Yes
No
Name(s) of person listed in Question 9
Employer Name
Employer Address
Employer Telephone Number
If self-employed write “Self”
Monthly pay before any deduction: (Gross)
Monthly TAKE HOME pay (Net)

Form SSA-2032-BK

(3-2007)

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13. A. Do you, your spouse or any dependent member of your household receive
support or contributions from any person or organization?
Yes
If yes, answer 13.B.
No
If no, skip to Question 14.
.

B. How much money is received each month?
Amount $ _________ (Show this amount on line K of Question 14.)
Source of support or contributions __________________________

MONTHLY INCOME

BE SURE TO SHOW MONTHLY AMOUNTS BELOW. 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).

14. INCOME
YOURS
FROM
#12 & #13
ABOVE, AND
OTHER INCOME
TO YOUR
HOUSEHOLD
A. TAKE HOME Pay
(Net) (From #12 A, B
and C above)
B. SVB

SPOUSE’S

C. SOCIAL
SECURITY
RETIREMENT &
SURVIVORS
BENEFITS (e.g.,
spouse/widow[er]
benefits)
D. SUPPLEMENTAL
SECURITY INCOME
(SSI)
E. PENSIONS (VA,
TYPE
PVAO,PSSS,Military,
Civil Service,
Railroad, etc.)

Form SSA-2032-BK

(3-2007)

Page 9

OTHER
HOUSEHOLD
MEMBERS

SSA
USE
ONLY

YOURS

F. PUBLIC
ASSISTANCE
(Other than SSI)

SPOUSE’S

TYPE

G. FOOD STAMPS
(Show full face value
of stamps received)
H. INCOME FROM
REAL ESTATE (rent,
etc.) (From #11B
above)
I. ROOM AND/OR
BOARD
PAYMENTS
(Explain in Remarks,
below)
J. CHILD SUPPORT
AND/OR ALIMONY
K. OTHER SUPPORT
(From #13B above)
L. INCOME FROM
ASSETS (From #10
above)
M. OTHER (From any
source, explain below)
TOTALS

GRAND TOTAL; (Add total of 3 blocks from Question 14.)

REMARKS

Form SSA-2032-BK

(3-2007)

Page 10

OTHER
HOUSEHOLD
MEMBERS

SSA
USE
ONLY

MONTHLY HOUSEHOLD EXPENSES
BE SURE TO SHOW MONTHLY EXPENSES BELOW. 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).
DO NOT list an expense that is withheld from income (such as Medical Insurance under
Medicare). 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 15.F.
15. MONTHLY HOUSEHOLD EXPENSES

Amount
per month

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.
Utilities (gas, electricity, telephone)
Other heating/cooking fuel (oil, propane, coal, wood, etc.)
Clothing
Credit card payments
(Show minimum monthly payment allowed.)
Property tax
Other taxes or fees related to your home
(trash collection, water-sewer fees)
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.)
Other transportation
Church-charity cash donations

C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
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

Form SSA-2032-BK

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Page 11

SSA
USE
ONLY

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

INCOME AND EXPENSES COMPARISON
Amount
16. A.
B.

17.

Monthly Income
(Write the amount from the Grand Total of Question #14.)
Monthly Expenses
(Add $10 to the amount from the Total of Question #15.)

If your expenses shown in 16.B. are
more than your income shown in 16.A.,
explain how you are paying your bills in
the space below.

FOR SSA USE ONLY
INCOME
EXCEEDS
MONTHLY
EXPENSES

Income=

INCOME
LESS THAN
MONTHLY
EXPENSES

Income=

+

–

FINANCIAL EXPECTATION AND FUNDS AVAILABILITY
18.

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: Expect tax refund, pay raise or full repayment of a
current bill for the better; or major house repairs expected for the worse.)
Yes
If yes, explain on line below.
No

Form SSA-2032-BK

(3-2007)

Page 12

REMARKS SPACE: If you are continuing an answer to a question, please show the
number and letter (if any) of the question you are responding to.

IMPORTANT: 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
PRINT (First name, middle initial, last name in ink)
DATE (MM/DD/YY)
HOME TELEPHONE
NUMBER (Include area
code)
SIGNATURE (Sign Here)
WORK TELEPHONE
NUMBER IF WE MAY
CALL YOU AT WORK
(Include area code)

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

CITY AND STATE/
COUNTRY

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, Country)

Form SSA-2032-BK

(3-2007)

ADDRESS (Number and street, City,
State and Zip Code, Country)

Page 13

THE PRIVACY AND PAPERWORK REDUCTION ACTS
The information requested on this form is sought pursuant to the authority granted in 42
U.S.C. 404, 1008, 1383(b), 1395gg, the Social Security Protection Act of 2004 (P.L. 108-203)
and the Federal Coal Mine Health and Safety Act of 1969. Your response to the
questions on this form is required for you to continue to receive benefits. Failure to
report those events which can cause suspension of benefits may cause the loss of
additional benefits.

See Revised Privacy Act Statement Attached

The information provided will be used to confirm past and continuing entitlement to
benefits and may be disclosed by SSA to another person or to another governmental
agency for the following purposes: (1) to assist SSA in establishing the right of an
individual to Social Security coverage and/or benefits; (2) to facilitate statistical research
and audit activities necessary to assure the integrity and improvement of the Social
Security programs; (3) to comply with Federal laws requiring the exchange of
information between SSA and another agency; and (4) to comply with the Freedom of
Information Act (5 U.S.C. 552).
We may also use the information you give us when we match records by computer.
Matching programs compare our records with those of other Federal, State or local
government agencies. Many agencies may use matching programs to find or prove that a
person qualifies for benefits paid by the Federal government. The law allows us to do
this even if you do not agree to it.
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.
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 120 minutes to read the instructions, gather the facts,
and answer the questions. Send only comments on our time estimate above to SSA,
6401 Security Blvd., Baltimore, MD 21235-6401.

Form SSA-2032-BK

(3-2007)

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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

Sections 204, 808, 1631(b), and 1870 of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide to decide if we can waive
collection of the overpayment or change the amount you must pay us back each month.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent us from waiving collection of the overpayment or change the amount
you must repay us each month. Failure to report all events, which can cause suspension of
benefits, may also cause the loss of additional benefits.
We rarely use the information you supply for any purpose other than determining continuing
eligibility. However, we may use the information for the administration of our programs
including sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notices entitled, Master Beneficiary Record (600090) and the Recovery of Overpayments, Accounting and Reporting/Debt Management System
(60-0094). Additional information about this and other system of records notices and our
programs are available from our Internet website at www.socialsecurity.gov or at your local
Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.