Fillable Form SSA-632-BK Request for Waiver of Overpayment Recovery

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Form SSA-632-BK Request for Waiver of Overpayment Recovery

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Form SSA-632-BK (04-2019)
Discontinue Prior Editions
Social Security Administration
Request for Waiver of Overpayment Recovery
Page 1 of 14
OMB No. 0960-0037
When To Complete This Form
Complete this form if any of the following applies:
You think that you are not at fault for the overpayment and you cannot afford to pay the money back.
•
You think that you are not at fault and you think the overpayment is unfair for some other reason.
•
We will use your answers to decide if you have to pay the money back. If we decide you do not have to pay
the money back, we call it a waiver. If you also think we made a mistake when we decided that you were
overpaid, or if you disagree with the amount of your overpayment, please also complete the SSA-561,
Request for Reconsideration. We call this action an appeal.
When Not To Complete This Form
If you do not wish to request a waiver, but you think we made a mistake when we decided that you
were overpaid, or if you disagree with the amount of your overpayment. Instead, please complete the
SSA-561, Request for Reconsideration.
•
You are requesting a hearing before an Administrative Law Judge. Instead, please complete the
HA-501-U5, Request for Hearing by Administrative Law Judge.
•
You only want to change the amount of money you must pay us back each month. Instead, please
complete the SSA-634, Request for Change in Overpayment Recovery Rate.
IMPORTANT: Please answer the following questions as completely as you can and submit any supporting
documents with your waiver request. If you need more space for answers, use the "REMARKS" section on
page 11.
1. A. What is the name, Social Security Number, and claim number (if any) of the overpaid person?
Name:
SSN:
Claim Number:
B. Are you the overpaid person?
Yes (go to 4) No (go to 1.C)
C. If you are filling out the waiver request for 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 spouse.
I am the overpaid person's representative payee.
I am the overpaid person's legal guardian.
Other, please explain:
•
You have been convicted of fraud relating to this overpayment.
•
SECTION 1 - IDENTIFYING QUESTIONS
(Options continue on next page)
Form SSA-632-BK (04-2019) UF Page 2 of 14
D. If you are not the overpaid person, what is your name or the name of the organization
you represent?
1.
Name:
E. If you are the overpaid person's representative payee, were you the representative payee when
the overpayment occurred?
Yes No
2.
A. Was the overpaid person living with you when he or she was overpaid?
Yes No
D. Did you tell us about the change or event that caused the overpayment?
NoYes
E. Do you still have any of the overpaid money?
No (go to 2.G)Yes (go to 2.F)
F. How much of the overpaid money do you still have? $
G. Did you use the overpaid money for the beneficiary?
No (go to 2.H)Yes
H. Explain how you used the overpaid money:
SECTION 2 - QUESTIONS FOR REPRESENTATIVE PAYEE
SECTION 3 - IF YOU ARE RESPONSIBLE FOR A FAMILY MEMBER'S OR ANOTHER
INDIVIDUAL'S OVERPAYMENT
3.
A. Did we tell you in the overpayment notice that you are responsible for paying back another
individual's overpayment?
No (go to 4)Yes (go to 3.B)
B. Was the overpaid person living with you when he or she was overpaid?
NoYes
C. Did you receive any of the overpaid money?
NoYes
SECTION 4 - INFORMATION ABOUT RECEIVING THE OVERPAYMENT
IMPORTANT: Please complete questions 4 through 26 as completely as you can. If you are answering the
questions for someone else or if you are helping someone fill out the form, check the boxes and answer
each question as it applies to the overpaid person.
4. What was your situation when the overpayment occurred? (Check all that apply)
I was a child when the overpayment occurred.
I was an adult when the overpayment occurred.
B. Does the overpaid person currently live with you?
NoYes
C. Are you requesting a waiver for a minor child?
NoYes
IMPORTANT: If we told you in the overpayment notice that you are responsible for a family member's
overpayment, complete Section 3. Otherwise, go to Section 4.
IMPORTANT: If you were the representative payee for the overpaid person when the overpayment
occurred, complete Section 2 as it applies to you as the representative payee. Otherwise, go to Section 4.
I was receiving disability benefits from Social Security.
(Options continue on next page)
Do you have the notice for this overpayment?
If you have the notice for this overpayment, please provide the date on that notice.
None of the above, please explain:
What is your reason for requesting a waiver? (Check all that apply)
F.
What was the cause of the overpayment?
(Check all that apply)
J.
I.
H.
G.
F.
E.
D.
C.
B.
A.
I received too much income.
E.
C.
D. I thought I still had a disability that would make me eligible for benefits. I filed an appeal and I
fully cooperated with Social Security.
B.
Page 3 of 14
4.
I was receiving retirement benefits from Social Security.
I was receiving Social Security benefits from a parent's record.
I was receiving Social Security benefits as a widow/widower.
I was receiving Supplemental Security Income (SSI) payments.
5.
A.
The overpayment was not my fault.
I cannot afford to pay the money back.
The overpayment is unfair for other reasons.
Please explain:
I was age 18 and receiving SSI when the overpayment occurred.
Have you previously filed a waiver request for this overpayment?7.
NoYes
8.
(MM/DD/YYYY)
9.
If you have the notice for this overpayment, please provide the following information:
First month you were overpaid
Last month you were overpaid
If you were overpaid only one month, please provide the month
10.
If you have the notice for this overpayment, please provide the amount of the overpayment. $
11.
My household received too much income.
My resources were over the amount for SSI.
I received help for food and shelter.
I received more than one benefit payment for the same month.
The Social Security Administration determined that I was no longer disabled.
My marital status changed.
I received workers' compensation.
I was in a nursing home.
I was in jail or prison.
I was receiving Social Security benefits as a spouse.
None of the above, please explain:
Are you requesting a waiver for your entire overpayment amount?6.
NoYes
(Options continue on next page)
No (go to 11)Yes
Form SSA-632-BK (04-2019) UF
K.
Q.
R.
P.
O.
N.
Form SSA-632-BK (04-2019) UF Page 4 of 14
11.
My attorney fee was not withheld from my benefits.
I was no longer a student.
I no longer had a child under age 16 or a disabled child in my care.
12. A. Do you understand that you are supposed to report changes to us, for example:
• working
• marriage
• divorce
• moving
• a change in resources
• a change in income
• a change in school attendance
• any other changes that may affect your benefits
No, explain:
Yes
B. Is there anything that prevents you from reporting your changes to us?
NoYes, please explain:
C. Did you tell us about the change or event that led to the overpayment?
Yes, please check one or more reasons below No, please explain:
I called in
I sent a fax or letter
I visited a local field office
I used electronic wage reporting
Other, please explain:
Date(s) you told us about the change or event that led to the overpayment:
Do you have any documentation indicating that you told us about the change or event that led
to the overpayment?
No, please explain:
Yes, please send it with your waiver request
D. Have you ever been overpaid before?
No (go to 12.F)Yes (go to 12.E)
M.
L.
Another person became entitled on the same record.
My immigration status changed.
I was overpaid because:
I do not know why I was overpaid.
I lived outside the U.S. for 30 consecutive days.
IMPORTANT: To complete Sections 5 through 8 of this form, you should refer to certain 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
waiver. Submit similar documents for your spouse and your dependents. A dependent is a person who
depends on you for support and whom you can claim on your tax return.
Examples of supporting documents are:
Form SSA-632-BK (04-2019) UF Page 5 of 14
E. If you were overpaid before, is this overpayment for the same reason?
12.
NoYes
F. Are you currently receiving any of the following? (Check all that apply)
I am receiving Supplemental Security Income (SSI) payments.
I am receiving Temporary Assistance for Needy Families (TANF).
My claim number is:
I am receiving a pension based on need from the Department of Veterans Affairs (VA)
My claim number is:
IMPORTANT: If you checked any boxes in question 12.F, go to page 13. Please sign, date, provide your
address and phone number(s), and proof that you receive TANF or VA pension, if applicable. If this
statement does not apply, go to question 13.A.
13.
A. Did you still have any of the overpaid money at the time you received the overpayment notice?
• Current Rent or Mortgage Information
• 2 or 3 Recent Utility, Medical, Charge Card,
and Insurance Bills
• Canceled Checks
No (go to 14)Yes
Amount $
(go to 13.B)
B. Do you still have any of the overpaid money?
NoYes
Amount $
14.
Did you receive any real estate after you received the overpayment notice?
Value: $
Yes (provide the value) No
15.
A. Did you give away any real estate after you received your overpayment notice?
Value: $
Yes (provide the value) No
B. Did you sell any real estate after you received your overpayment notice?
No
Amount you received after selling: $
Yes (provide the amount)
I do not know
• Recent Bank Statements (checking or
savings account)
• Current Pay Stubs
• Your Most Recent Income Tax Return
Documents to Support Your Statements
SECTION 5 - YOUR FINANCIAL STATEMENT
(If yes, return the money to SSA following the instructions in the
overpayment notice or contact SSA at 1-800-772-1213.)
Please write only whole dollar amounts. Round any cents to the nearest dollar.
Form SSA-632-BK (04-20197) UF Page 6 of 14
16.
A. Did you give away any money after you received the overpayment notice?
NoYes (provide the amount)
Amount: $
SECTION 6 - MEMBERS OF HOUSEHOLD
17.
A. If you are an adult requesting a waiver, list your spouse and dependents below. A dependent is a
person who depends on you for support and whom you can claim on your income tax return.
If you are completing the waiver request for a minor child, only provide the child's name in
Section 6 and the child's information is Sections 7, 8, and 9. If the child's income and assets help
with food and household expenses, complete Sections 6, 7, 8, and 9 with the parents' and their
dependents' information.
Name Relationship To YouAge
B. Does anyone live with you who you cannot claim on your income tax return?
No (go to 18.A)Yes
If yes, does this person or persons give you any money to live with you or pay any of the household
bills or expenses?
NoYes,
total amount you receive $
SECTION 7 - ASSETS - THINGS YOU HAVE AND OWN
18.
A. How much cash do you, your spouse, and your dependents have in your possession? $
B. List all financial accounts for you, your spouse, and your dependents. 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
B. Did anyone give you money after you received your overpayment notice?
No
Amount: $
Yes (provide the amount)
B. Is your spouse employed?
Take home pay or earnings if
self-employed (Net) Choose one:
Form SSA-632-BK (04-2019) UF Page 7 of 14
A. Do you, your spouse, or your dependents own more than one family vehicle, including a car, sport
utility vehicle (SUV), truck, van, camper, motorcycle, boat, or any other vehicle?
No (go to 19.B)Yes (list all of the vehicles below)
Owner Main Purpose for UsePresent Value
Loan Balance
(if any)
Year, Make/Model
B. Do you, your spouse, or your dependents own any real estate other than where you live?
No (go to 19.C)Yes (list below)
Owner Income AmountMarket Value
Loan Balance
(if any)
Description
C. Do you, your spouse, or your dependents own or have an interest in any business, property, or valuables?
No (go to 20)Yes (list below)
Owner Income AmountMarket Value
Loan Balance
(if any)
Description
SECTION 8 - MONTHLY HOUSEHOLD INCOME
The next set of questions are about monthly take home pay. Enter your, your spouse, and your dependents'
take home pay and check the box to show whether payment is received weekly, every 2 weeks, twice a
month, or monthly. Add the monthly amount on line 22.A. If you need more space for answers, use the
"REMARKS" section on page 11.
20.
A. Are you employed?
No (go to 20.B)Yes (provide information below)
Employer(s) Name, Address, and Phone: (Write "self" if self-employed)
Take home pay or earnings if
self-employed (Net) Choose one:
Weekly
Monthly Twice a Month
Every 2 Weeks
$
$
Twice a Month
Every 2 Weeks
Monthly
Weekly
Employer(s) Name, Address, and Phone: (Write "self" if self-employed)
No (go to 20.C)Yes (provide information below)
19.
(Options continue on next page)
TOTALS $
TOTALS $
TOTAL COUNTABLE VALUE $
SSA
Use
Only
SSA
Use
Only
Dependent(s) of
Overpaid Person
(Total)
SSA
Use
Only
Form SSA-632-BK (04-2019) UF Page 8 of 14
20.
C. Are any of your dependents employed, including self-employment?
No (go to 21)Yes (provide information below)
Name(s) of dependents:
21.
A. Do you, your spouse, or your dependents receive support or contributions from any person,
agency, or organization?
No (go to 22)Yes (go to 21.B)
C. How much money do you, your spouse, or your dependents receive each month?
(Show this amount on line I of question 22)
$ Source
22.
Income
(Be sure to show monthly
amounts below)
A. Take Home Pay (Net)
(from questions 20.A, 20.B, and 20.C)
Overpaid
person's
income
Spouse of
Overpaid
Person
B. Social Security Benefits (retirement,
disability, widows, students, etc.)
C. Supplemental Security Income (SSI)
D. Pension(s)
(VA, Military, Civil
Service, Railroad, etc.)
E. Supplemental Nutrition Assistance
Program (SNAP) Benefits
F. Income from Real Estate, Business, etc.
(from questions 19.B and 19.C)
G. Room and/or Board Payments from a
Person who is not a Dependent (from
question 17.B). Put the amount in the
overpaid person's column.
H. Child Support/Alimony
I. Other Support
(from question 21.C)
J. Income from Assets
(from question 18.B)
K. Other (from any source, explain in
REMARKS on next page)
TOTALS:
Grand Total $
(Add all TOTAL blocks above)
TYPE
TYPE
(Options continue on next page)
B. Is the support received under a loan agreement?
No (go to 21.C)Yes (go to 22)
$
Provide total monthly take home pay for dependent(s):
SSA
Use
Only
Form SSA-632-BK (04-2019) UF Page 9 of 14
22.
REMARKS:
SECTION 9 - 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 amounts in number 23) Please write only
whole dollar amounts and round any cents to the nearest dollar.
Type of Expense
23.
A. Rent or Mortgage (if mortgage payment includes property or other local taxes, insurance,
etc., DO NOT list it again below)
$ Per Month
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.)
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)
I. Medical/Dental (prescriptions and medical equipment, if not paid by insurance)
J. Loan/Lease Payment for Family Vehicle
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
TOTAL
E. Clothing
K. Expenses (gas and repairs) for Family Vehicle
P. Any expenses not shown above
(Options continue on next page)
E. TOTAL (Subtract D from A)
Form SSA-632-BK (04-2019) UF Page 10 of 14
C. Add this amount to your expenses.
23.
EXPENSE REMARKS (Please provide any additional information not captured in Section 9)
SECTION 10 - INCOME AND EXPENSES COMPARISON
24.
A. Monthly Income
Write the amount here from the Grand Total from number 22.
$
B. Monthly Expenses
Write the amount here from the Total from number 23.
$
D. Adjusted Monthly Expenses (Add B and C) $
25.
If your expenses in 24.D are more than your income in 24.A, explain how you are paying your bills.
If you are not paying your bills, explain which bills have unpaid balances.
SECTION 11 - FINANCIAL EXPECTATION AND FUNDS AVAILABILITY
26.
A. Do you expect to receive an inheritance within the next 6 months?
Yes, explain No (go to 26.B)
$
B. Please provide the total of you, your spouse, and your dependents' assets from questions, 18.A,
18.B, 19.A, 19.B, and 19.C.
Total $:
(Options continue on next page)
If you are continuing an answer to a question, please write the number (and
letter, if any) of the question first.
C. Is there any reason you cannot convert or sell the “Balance or Value” of any financial assets shown
in items 18.B, 19.A, 19.B or 19.C to cash?
REMARKS SECTION -
Form SSA-632-BK (04-2019) UF Page 11 of 14
IMPORTANT: Please provide your documents to support the information you provided. Complete and sign
the following statements.
26.
No
Yes, explain
Please review the following, make selection, and sign below:
I understand:
Form SSA-632-BK (04-2019) UF Page 12 of 14
Below is an authorization for the Social Security Administration to obtain your financial account information.
We may need to access your financial records in order to determine if we can waive your overpayment.
IMPORTANT: If the overpaid individual is a minor child, a parent or legal guardian must complete and sign
the form on the child's behalf. If a court has assigned a legal guardian to an adult individual, the legal
guardian must complete and sign the form. Adults who do not have a court appointed legal guardian must
complete and sign the form, even if they have a representative payee.
AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN ACCOUNT RECORDS
FROM A FINANCIAL INSTITUTION AND REQUEST FOR RECORDS
I authorize any custodian of records at any financial institution to disclose to the Social Security
Administration any records about my financial business or that of the person named above whom I
legally represent or whose benefits I manage.
I do not authorize any custodian of records at any financial institution to disclose to the Social
Security Administration any records about my financial business or that of the person named
above whom I legally represent or whose benefits I manage. I understand that if I do not give
permission to obtain financial records or if I cancel my permission, SSA may not approve my
waiver request.
Customer's Signature/Authorization
Mailing Address Date
Date
Legal Representative's Mailing Address
Legal Representative's
Signature/Authorization
• I have the right to revoke this authorization at any time before any records are disclosed;
• The Social Security Administration may request all records about me from any financial institution;
• Any information obtained will be kept confidential;
• I have the right to obtain a copy of the record which the financial institution keeps concerning the
instances when it has disclosed records to a government authority unless the records were disclosed
because of a court order;
• This authorization is not required as a condition of doing business with any financial institution.
• The Social Security Administration will request records to determine the ability to repay an
overpayment in conjunction with a waiver determination;
• Failing to provide or revoking my authorization may result in the Social Security Administration
determining, on that basis, that adjustment or recovery of the overpayment will not deprive me of
funds to pay my bills for food, clothing, housing, medical care, or other necessary expenses;
• This authorization is in effect until the earliest of: 1) a final decision on whether adjustment or
recovery of my overpayment would deprive me of funds to pay my bills for food, clothing, housing,
medical care, or other necessary expenses; or 2) my revocation of this authorization in written
notification to the Social Security Administration.
Form SSA-632-BK (04-2019) UF Page 13 of 14
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 statement about a material fact in this information, or causes someone
else to do so, commits a crime and may be subject to a fine or imprisonment.
SIGNATURE OF OVERPAID PERSON OR REPRESENTATIVE PAYEE
Signature (First name, middle initial, last name) (Write in ink) Date (MM/DD/YYYY)
Home Telephone Number (include area code)
Work Telephone Number If We May Call You At
Work (include area code)
Mailing Address (Number and street, Apt. No., PO Box, or Rural Route
City State 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.
1. Signature of Witness (Write in ink) 2. Signature of Witness (Write in ink)
Address (Number and street, City, State, and ZIP Code) Address (Number and street, City, State, and ZIP Code)
- This information collection meets the clearance 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 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. You may send comments on our time estimate above to: SSA, 1338 Annex
Building, Baltimore, MD 21235-0001. Send only comments relating to our time estimate to this
address, not the completed form.
Form SSA-632-BK (04-2019) UF Page 14 of 14
Sections 204, 1631, and 1879 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 an accurate and timely decision on your overpayment waiver request.
We will use the information to make a waiver determination and to obtain your financial account information.
We may also share your information for the following purposes: called routine uses:
• To student volunteers and other worker, who technically do not have the status of Federal
employees, when they are performing work for Social Security Administration (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 third party contacts such as private collection agencies and credit reporting agencies under
contract with SSA and other agencies, including the Veterans Administration, the Armed Forces,
the Department of the Treasury, and State motor vehicle agencies, for the purposes of their
assisting SSA in recovering program debt.
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 Notices (SORN) 60-0094,
entitled Recovery of Overpayments, Accounting and Reporting/Debt Management System, as published in
the Federal Register (FR) on August 23, 2005, at 70 FR 49354; 60-0231, entitled Financial Transactions of
SSA Accounting and Finance Offices, as published in the FR on January 11, 2006, at 71 FR 1849; and
60-0320, entitled Electronic Disability Claims File, as published in the FR on July 25, 2006, at 71 FR 42159.
Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/
privacy.
Privacy Act Statement
Collection and Use of Personal Information
Paperwork Reduction Act Statement
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Form SSA-632-BK Request for Waiver of Overpayment Recovery

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Completed 20 February 2020

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