Form SSA-634 Request for Change in Repayment Notice

Form SSA-634 (XX-20XX)
Discontinue Prior Editions
Social Security Administration

Page 1 of 7
OMB No. 0960-0037

Request for Change in Overpayment Recovery Rate
When To Complete This Form
Complete this form if you are requesting that we adjust the current rate of withholding to recover your
overpayment because you are unable to meet your necessary living expenses. We will use your answers to
decide if we can reduce the amount you must pay us back each month.
IMPORTANT: Please answer the following questions as completely as you can. If you are answering the
questions for someone else, check the boxes and answer each question as it applies to the overpaid person.

SECTION 1 - IDENTIFYING QUESTIONS
1.

A. What is the name, Social Security Number, and claim number (if any) of the overpaid person?
Name:
SSN:
B. Are you the overpaid person?

Claim Number:
Yes (go to question 2)

No (go to question 1.C)

C. If you are not the overpaid person, what is your relationship to the overpaid person?
(Check all that apply)
I am the overpaid person's parent.

I am the overpaid person's representative payee.

I am the overpaid person's spouse.

I am the overpaid person's legal guardian.

Other, please explain:

D. If you are not the overpaid person, what is your name or the name of the organization you
represent?
Name:
2. Please check all that apply:
I am receiving Supplemental Security Income (SSI) benefits.
I am receiving Temporary Assistance for Needy Families (TANF)
I am receiving a pension based on need from the Department of Veterans Affairs (VA)
I am receiving Social Security benefits.
I am not receiving benefits.
3.

Enter the total amount you owe:

$

4.

Enter the amount you can afford to pay or have
withheld from your payment each month:

$

Form SSA-634 (XX-20XX)

Page 2 of 7

YOUR FINANCIAL STATEMENT
Documents to Support Your Statements
Please answer all questions and submit any supporting documents with your request. Your supporting
documents should be no older than 3 months from the date you are requesting a change in the repayment
rate.
Examples of supporting documents are:
• Current Rent or Mortgage Information
• 2 or 3 Recent Utility, Medical, Charge Card, and
Insurance Bills
• Canceled Checks

• Recent Bank Statements (checking or savings
account)
• Current Pay Stubs
• Your Most Recent Income Tax Return

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.

SECTION 2 - ASSETS - THINGS YOU HAVE AND OWN
5.

A. How much cash do you have in your possession? $
B. List all of your financial accounts. Examples of accounts you should list include: Checking, Online
(e.g., PayPal), Savings, Certificate of Deposit (CD), Individual Retirement Accounts (IRAs), Money
or Mutual Funds, Stocks, Bonds, Trust Funds, Prepaid Debit Cards, or any other accounts.
Type of
Account

Name and Address
of Institution

Name on
Account

Balance or
Value

Income Per
Month (interest
or dividends)

Account Number

TOTALS $

6.

A. Do you own more than one family vehicle, including a car, sport utility vehicle (SUV), truck, van,
camper, motorcycle, boat, or any other vehicle?
Yes (list all the vehicles below)
No (go to 6.B)
Owner

Year/Make/Model

Present
Value

Loan Balance
(if any)

Main Purpose for Use

TOTAL COUNTABLE VALUE $

(Options continue on next page)

Form SSA-634 (XX-20XX)

6.

Page 3 of 7

B. Do you own any real estate other than where you live?
Owner

Yes (list below)

Description

Market Value

No (go to 6.C)
Loan Balance
(if any)

Income
Amount

TOTALS $

C. Do you own or have an interest in any business, property, or valuables?
Yes (list below)
Description

Owner

Market Value

No (go to 7)
Loan Balance
(if any)

Income
Amount

TOTALS $

SECTION 3 - MONTHLY HOUSEHOLD INCOME
The next question asks about monthly take home pay. Enter your take home pay, and check the box to
show whether you are paid weekly, every 2 weeks, twice a month, or monthly. Add the monthly amount on
line 9.A.
7. Are you employed?

Yes (provide information below)

Employer Name, Address, and Phone: (Write "self" if self-employed)

No
Take home pay or earnings if self- $
employed (Net) Choose one:
Weekly

Every 2
Weeks

Twice a
Month

Monthly

8. A. Do you receive support or contributions from any person or organization?
Yes (go to question 8.B)
No (go to question 9)
B. Is the support received under a loan agreement?
Yes (go to question 9)
No (go to question 8.C)
C. How much money do you receive each month? (Show this amount on line I of question 9)
$
9.

Source

Income (Be sure to show monthly amounts below)

Your Income

SSA USE
ONLY

A. Take Home Pay (Net) (from question 7)
B. Social Security Benefits (retirement, disability, widows, students,
etc.)
C. Supplemental Security Income (SSI)
(Options continue on next page)

Form SSA-634 (XX-20XX)

9.

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

Page 4 of 7

TYPE
TYPE

E. Supplemental Nutrition Assistance Program (SNAP) Benefits
F. Income from Real Estate, Business, etc.
(from question 6.B and 6.C)
G. Room and/or Board Payments from a person who is not a
Dependent. Explain in Remarks below.
H. Child Support/Alimony
I. Other Support (from question 8.C)
J. Income from Assets (from question 5.B)
K. Other (from any source, explain in REMARKS below)
TOTAL:

REMARKS:

SECTION 4 - MONTHLY HOUSEHOLD EXPENSES
DO NOT list an expense that is withheld from your paycheck (such as medical insurance, child support,
alimony, wage garnishments, etc.). (Be sure to show monthly average amounts in number 10).
Please write only whole dollar amount and round any cents to the nearest dollar.
10.
SSA USE
Type of Expense
$ Per Month
ONLY
A. Rent or Mortgage (if mortgage payment includes property or other
local taxes, insurance, etc., DO NOT list again below)
B. Food (groceries, including food purchased with SNAP benefits,
and food at restaurants, work, etc.)
C. Utilities (Gas, electric, telephone (cell or land line), Internet, trash
collection, water, and sewer)
D. Other Heating/Cooking Fuel (oil, propane, coal, wood, etc.)
E. Clothing
F. Household Items (personal hygiene items, etc.)
G. Property Tax (State and local)
H. Insurance (life, health, fire, homeowner, renter, car, and any other
casualty or liability policies)
(Options continue on next page)

Form SSA-634 (XX-20XX)

Page 5 of 7

10. I. Medical/Dental (prescriptions and medical equipment, if not paid
by insurance)
J. Vehicle Loan/Lease Payment
K. Vehicle Expenses (gas and repairs)
L. Other Transportation (bus, taxi, etc., used for medical
appointments, work, or other necessary travel)
M. Tuition and School Expenses
N. Court Ordered Payments Paid Directly to the Court
O. Credit Card Payments (show minimum monthly payment).
DO NOT include any expenses already listed above
P. Any expense not shown above

TOTAL
EXPENSE REMARKS: (Please provide any additional information not included above. Also, explain
any unusual or very large expenses such as medical, college, etc.)

SECTION 5 - INCOME AND EXPENSES COMPARISON
11. A. Your Monthly Income
Write the amount here from "Total" of question 9.

$

B. Your Monthly Expenses
Write the amount here from "Total" of question 10.

$

C. Total
Subtract B from A.

$

12. If your expenses in 11.B are more than your income in 11.A, explain how you are paying your bills.
If you are not paying your bills, explain which bills have unpaid balances.

Form SSA-634 (XX-20XX)

Page 6 of 7

SECTION 6 - FINANCIAL EXPECTATION AND FUNDS AVAILABILITY
13. A. Do you expect to receive an inheritance within the next 6 months?
Yes (Explain on line below)
No (go to 13.B)

B. Is there any reason you cannot convert or sell the “Balance or Value” of any financial assets
shown in items 5.B, 6.A, 6.B, or 6.C to cash?
Yes (Explain on line below)

No

C. Please provide the total of your assets from questions, 5.A, 5.B, 6.A, 6.B, and 6.C
Total $:

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-634 (XX-20XX)

Page 7 of 7

Privacy Act Statement
Collection and Use of Personal Information
Sections 204 and 1631 of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent us from negotiating a repayment agreement and an accurate and timely determination on your
request for a change in your overpayment recovery rate.
We will use the information you provide to determine if we can approve your request for a change in your
overpayment recovery rate. We may also share the information for the following purposes, called routine
uses:
• To student volunteers and other workers, who technically do not have the status of Federal
employees, when they are performing work for SSA as authorized by law, and they need access to
personally identifiable information in SSA records in order to perform their assigned Agency
functions; and
• To contractors and other Federal agencies, as necessary, for the purpose of assisting us in the
efficient administration of its programs. We will disclose information under this routine use only in
situations in which we may enter into a contractual or similar agreement to obtain assistance in
accomplishing an SSA function relating to this system of records.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person’s eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0094,
entitled Recovery of Overpayments, Accounting and Reporting/Debt Management System (ROAR/DMS), as
published in the Federal Register (FR) on August 23, 2005, at 70 FR 49354; 60-0231, entitled Social
Security Online Accounting and Reporting System, as published in the FR on January 14, 2020 at 85 FR
2224; and 60-0320, entitled Electronic Disability (eDIB) Claim File, as published in the FR on June 4, 2020,
at 85 FR 34477. Additional information, and a full listing of all our SORNs, is available on our website at
www.ssa.gov/privacy.
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 45 minutes 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 1-800-325-0778). You may send comments regarding this burden estimate or any
other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate or other aspects of this
collection to this address, not the completed form.