Fillable Ssa-632 Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate

Fill Online, Printable, Fillable, Blank Ssa-632 Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate Form

Use Fill to complete blank online U.S. SOCIAL SECURITY ADMINISTRATION pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Ssa-632 Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate

On average this form takes 83 minutes to complete

The Ssa-632 Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate form is 9 pages long and contains:

  • 0 signatures
  • 90 check-boxes
  • 290 other fields

Country of origin: US
File type: PDF

BROWSE U.S. SOCIAL SECURITY ADMINISTRATION FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Form SSA-632-BK (01-2018) UF
Discontinue Prior Editions
Social Security Administration
Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate
Page 1 of 9
OMB No. 0960-0037
FOR SSA USE ONLY
ROAR Input
Yes
No
Waiver
Approval
Denial
SSI Yes No
AMT OF OP $
1.
B. Social Security Number:
2. Check any of the following that apply. (Also, fill in the dollar amount in B, C, or D.)
A.
I cannot afford to use all of my monthly benefit to pay back the overpayment. However I can
afford to have $ withheld each month.
I am no longer receiving Supplement Security Income (SSI) payments. I want to pay back
$ each month instead of paying all of the money at once.
I am receiving SSI payments. I want to pay back $ each month instead of
paying 10% of my total income.
PERIOD (DATES) OF OP
Input Date
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.
A. Name of person on whose
record the overpayment occurred:
C. Name of overpaid person(s) making this request and his or her Social Security Number(s):
The overpayment was not my fault and I cannot afford to pay the money back and/or it is
unfair for some other reasons.
B.
C.
D.
A. Was the overpaid person living with you when he/she was overpaid?
SECTION I - INFORMATION ABOUT RECEIVING THE OVERPAYMENT
3. A. Did you, as representative payee, receive the overpaid benefits to use for the beneficiary?
Yes
No (Skip to Question 4)
B. Name and address of the beneficiary
C. How were the overpaid benefits used?
4.
If we are asking you to repay someone else's overpayment:
Yes No
B. Did you receive any of the overpaid money?
Yes No
C. Explain what you know about the overpayment AND why it was not your fault.
5. 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?
6.
A. Did you tell us about the change or event that made you overpaid? If no, why
didn't you tell us?
Yes No
B. If yes, how, when and where did you tell us? If you told us by phone or in person, who did you
talk with and what was said?
C. If you did not hear from us after your report, and/or your benefits did not
change, did you contact us again?
Yes No
7.
A. Have we ever overpaid you before?
Yes No
B. 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.
If yes, on what Social Security number?
Form SSA-632-BK (01-2018) UF Page 2 of 9
SECTION II - YOUR FINANCIAL STATEMENT
FOR SSA USE ONLY
•
Current Rent or Mortgage Books
•
Savings Passbooks
•
•
Your most recent Tax Return
•
2 or 3 recent utility, medical, charge card,
and insurance bills
•
Canceled checks
•
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 7.
8.
A. Do you now have any of the overpaid checks or money in
your possession (or in a savings or other type of account)?
Yes
Return this
amount to SSA
No
B. Did you have any of the overpaid checks or money in your
possession (or in a savings or other type of account) at the
time you received the overpayment notice?
Yes
Amount:
Answer Question 9.
No
9.
Explain why you believe you should not have to return this amount.
10. A. Did you lend or give away any property or cash after notification
of the overpayment?
Yes (Answer Part B)
No (Go to question 11.)
B. Who received it, relationship (if any), description and value:
11. A. Did you receive or sell any property or receive any cash
(other than earnings) after notification of this overpayment?
Yes (Answer Part B)
No (Go to question 12.)
B. Describe property and sale price or amount of cash received:
12. A. Are you now receiving cash public assistance
such as Supplemental Security Income
(SSI) payments?
No
B. Name or kind of public assistance C. Claim Number
NAME:
You need to 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.
SSN:
EXAMPLES ARE:
Pay Stubs
Amount:
ANSWER 10 AND 11 ONLY IF THE OVERPAYMENT IS SUPPLEMENTAL SECURITY INCOME
(SSI) PAYMENTS. IF NOT, SKIP TO 12.
Yes (Answer B and C and See note below)
IMPORTANT: If you answered "YES" to question 12, DO NOT answer any more questions on this
form. Go to page 8, sign and date the form, and give your address and phone number(s). Bring or
mail any papers that show you receive public assistance to your local Social Security office as soon
as possible.
Form SSA-632-BK (01-2018) UF Page 3 of 9
Members Of Household
13.
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
14.
A. How much money do you and any person(s) listed in question 13 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
PER
MONTH
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
Enter the "Per Month" total
on line (k) of question 18.
15.
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
YEAR/MAKE/MODEL
PRESENT
VALUE
LOAN BALANCE
(if any)
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)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$ $
$
$
$
$
$
$
$
$
$
$
$
$
$
$
MAIN PURPOSE
FOR USE
USAGE-INCOME
(rent etc.)
Form SSA-632-BK (01-2018) UF Page 4 of 9
A. Do you, your spouse or any dependent member of your household
receive support or contributions from any person or organization?
A. Are you employed?
B. Is your spouse employed?
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 18 also.
YES (Provide information below) NO (Skip to B)
Monthly pay before
deduction (Gross)
$
Monthly TAKE-
HOME pay ( NET )
$
YES (Provide information below) NO (Skip to C)
Employer(s) name, address, and phone: (Write "self" if self-employed)
Monthly pay before
deduction (Gross)
$
Monthly TAKE-
HOME pay (NET)
$
C. Is any other person listed in
Question 13 employed?
YES
NO (Go to Question 17)
Name(s)
Employer(s) name, address, and phone: (Write "self" if self-employed)
Monthly pay before
deduction (Gross)
$
Monthly TAKE-
HOME pay (NET)
$
YES (Answer B)
NO (Go to question 18)
B. How much money is received each month?
(Show this amount on line (J) of question 18)
$
SOURCE
BE SURE TO SHOW MONTHLY AMOUNTS BELOW - If received weekly or every 2 weeks, read the instruction at the top
of this page.
18.
INCOME FROM #16 AND #17 ABOVE
AND OTHER INCOME TO YOUR HOUSEHOLD
YOURS SPOUSE'S
OTHER
HOUSEHOLD
MEMBERS
A. TAKE HOME Pay (Net)
(From #16 A, B, C, above)
$ $
B. Social Security Benefits
C. Supplemental Security Income (SSI)
D. Pension(s)
(VA, Military,
Civil Service,
Railroad, etc.)
TYPE
E. Public Assistance
(Other than SSI)
TYPE
F. Food Stamps (Show full face value of
stamps received )
G. Income from real estate
(rent, etc.) (From question 15B)
H. Room and/or Board Payments (Explain in
remarks below )
I. Child Support/Alimony
J. Other Support
(From #17 (B) above)
K. Income From Assets (From question 14)
L. Other (From any source, explain below)
REMARKS TOTALS
GRAND TOTAL
(Add 3 total blocks above)
SSA USE
ONLY
$
$ $ $
\/
\/ \/
$
Employer name, address, and phone: (Write "self" if self-employed)
16.
17.
TYPE
Form SSA-632-BK (01-2018) UF Page 5 of 9
Monthly Household Expenses
If the expense is paid weekly or every 2 weeks, read the instruction at the top of Page 5. 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).
19.
$ PER MONTH
SSA USE
ONLY
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)
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)
EXPENSE REMARKS (Also explain any unusual or very large
expenses, such as medical, college, etc.)
TOTAL
$
H. Other taxes or fees related to your home (trash collection,
water-sewer fees)
Form SSA-632-BK (01-2018) UF Page 6 of 9
FOR SSA USE ONLY
Income And Expenses Comparison
20.
A. Monthly income (Write the amount here from the "Grand Total" of
#18.)
B. Monthly Expenses (Write the amount here from the "Total" of #19.)
C. Adjusted Household Expenses
D. Adjusted Monthly Expenses (Add (B) and (C))
INC. EXCEEDS
ADJ EXPENSE
INC LESS THAN
ADJ EXPENSE
21.
If your expenses (D) are more than your income (A), explain
how you are paying your bills.
Financial Expectation And Funds Availability
22.
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
on line below)
NO
B. If there is an amount of cash on hand or in checking
accounts shown in item 14A, is it being held for a
special purpose?
NO (Amount on hand)
NO (Money available for any use)
YES (Explain on line below)
C. Is there any reason you CANNOT convert to cash the "Balance or Value"
of any financial asset shown in item 14B.
YES (Explain
on line below)
NO
D. Is there any reason you CANNOT SELL or otherwise convert to cash any
of the assets shown in items 15A and B?
YES (Explain
on line 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. (MORE SPACE ON NEXT PAGE)
$
$
$
$
$
+
-
Form SSA-632-BK (01-2018) UF Page 7 of 9
+$25
Form SSA-632-BK (01-2018) UF
REMARKS SPACE (Continued)
PENALTY CLAUSE, CERTIFICATION AND PRIVACY ACT STATEMENT
SIGNATURE OF OVERPAID PERSON OR REPRESENTATIVE PAYEE
SIGNATURE (First name, middle initial, last name) (Write in ink)
SIGN
HERE
DATE (Month, Day, Year)
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., P.O. Box, or Rural Route)
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)
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.
ADDRESS (Number and street, City, State,
and ZIP Code)
Page 8 of 9
Form SSA-632-BK (01-2018) UF
- 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 only comments relating to our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.
Sections 204, 1631(b), 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 or
change in repayment rate request.
We will use the information to make a determination regarding overpayment recovery and rate of
repayment. We may also share your information for the following purposes, called routine uses:
1. To employers to assist the Social Security Administration (SSA) in the collection of debt owed
by former beneficiaries and representative payees of Social Security payments who received
an overpayment and owe a delinquent debt to the SSA; and
2. To another Federal agency that has asked SSA to effect an administrative offset under
common law or under 31 U.S.C. 3716 to help collect a debt owed the United States.
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
(SORNs) 60-0094, entitled Recovery of Overpayments, Accounting and Reporting/Debt
Management System; 60-0231, entitled Financial Transactions of SSA Accounting and Finance
Offices; and 60-0320, entitled Electronic Disability Claims File. Additional information and a
full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.
Privacy Act Statement
Collection and Use of Personal Information
Paperwork Reduction Act Statement
Page 9 of 9
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Ssa-632 Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 June 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document