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

ICR 201403-0960-007 · OMB 0960-0037 · Object 45963901.

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SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0037

Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate
FOR SSA USE ONLY
ROAR Input

Yes
No

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.

Input Date
Waiver

Approval
Denial

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.

SSI

Yes

AMT OF OP $
PERIOD (DATES) OF OP

A. Name of person on whose record
the overpayment occurred:

B. Social Security Number

C. Name of overpaid person(s) making this request and his/her Social Security Number(s):

Check any of the following that apply. (Also, fill in the dollar amount in B, C, or D.)
A.

The overpayment was not my fault and I cannot afford to pay the money back and/or it is unfair for some
other reasons.

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 $
my total income.

Form SSA-632-BK (XX-200X) ef (XX-200X) Draft

Page 1

each month instead of paying 10% of

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?

If we are asking you to repay someone else's overpayment:
A. Was the overpaid person living with you when he/she was overpaid?
B. Did you receive any of the overpaid money?

Yes

C. Explain what you know about the overpayment AND why it was not your fault.

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?

A. Did you tell us about the change or event that made you overpaid?
If no, why didn't you tell us?

Yes

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?

A. Have we ever overpaid you before?

Yes

If yes, on what Social Security number?
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.

Form SSA-632-BK (XX-200X) ef (XX-200X) Draft

Page 2

FOR SSA USE ONLY
NAME:

SECTION II-YOUR FINANCIAL STATEMENT

SSN:

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.
EXAMPLES 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

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.

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
Amount:$
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

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

ANSWER 10 AND 11 ONLY IF THE OVERPAYMENT IS SUPPLEMENTAL SECURITY INCOME
PAYMENTS (SSI). IF NOT, SKIP TO 12.

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?
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?

Yes (Answer Part B)
No (Go to Question 12.)

Yes

(Answer B and C and
See note below)

B. Name or kind of public assistance

C. Claim Number

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 (XX-200X) ef (XX-200X) Draft

Page 3

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

PER MONTH

CERTIFICATES OF DEPOSIT (CD)

INDIVIDUAL RETIREMENT ACCOUNT (IRA)

MONEY OR MUTUAL FUNDS

BONDS, STOCKS

TRUST FUND

CHECKING ACCOUNT

OTHER (EXPLAIN)

SAVINGS (Bank, Savings and
Loan, Credit Union)

TOTALS

15.

BALANCE
OR VALUE

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 18.

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)

MAIN PURPOSE FOR USE

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

Form SSA-632-BK(XX-200X) ef (XX-200X) Draft

DESCRIPTION

Page 4

MARKET
VALUE

LOAN BALANCE
(if any)

USAGE-INCOME
(rent etc.)

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.

16.

YES (Provide information below)

A. Are you employed?

NO (Skip to B)

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

B. Is your spouse employed?

Monthly TAKE-HOME
pay (NET)

NO (Skip to C)
Monthly pay before
deduction (Gross)
Monthly TAKE-HOME
pay (NET)

$
$

Name(s)
YES
NO (Go to Question 17)

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

17.

YES (Provide information below)

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

C. Is any other person listed
in Question 13 employed?

Monthly pay before
deduction (Gross)

A. Do you, your spouse or any dependent member of your household
receive support or contributions from any person or organization?

Monthly pay before
deduction (Gross)

Monthly TAKE-HOME
pay (NET)

YES (Answer B)

NO (Go to question 18)

SOURCE

B. How much money is received each month?
$
(Show this amount on line (J) of question 18)

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

A. TAKE HOME Pay (Net)
(From #16 A, B, C, above)

YOURS

SPOUSE'S

OTHER
HOUSEHOLD
MEMBERS

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)

Form SSA-632-BK (XX-200X) ef (XX-200X) Draft

Page 5

SSA USE
ONLY

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

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)
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)

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.)

Form SSA-632-BK (XX-200X) ef (XX-200X) Draft

TOTAL

Page 6

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))

21.

$25

If your expenses (D) are more than your income (A),
explain how you are paying your bills.

FOR SSA USE ONLY
INC. EXCEEDS
ADJ EXPENSE

INC LESS THAN
ADJ EXPENSE

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).

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?

YES (Explain on
line below)
NO

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 (XX-200X) ef (XX-200X) Draft

Page 7

REMARKS SPACE (Continued)

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 OVERPAID PERSON OR REPRESENTATIVE PAYEE
DATE (Month, Day, Year)

SIGNATURE (First name, middle initial, last name) (Write in ink)

HOME TELEPHONE NUMBER (Include area code)

(

)

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

SIGN
HERE

(

)

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)

About the Privacy Act

See Revised
The Social Security Act (Sections 204, Privacy
1631(b), and
Act1870) and
the Federal Coal Mine Health and Safety Act of 1969 allow us to
collect the facts on this form. This form Statement
is voluntary. However, if
you do not give us the facts we ask for, we may not be able to
approve your waiver request. If we cannot collect the
overpayment, we may ask the Justice Department to collect it.
Sometimes the law requires us to give out the facts on this form
without your consent. We must give these facts to another person
or government agency if Federal law requires that we do so or to
do the research and audits needed to monitor and improve the
programs we manage.
We may also give these facts to the Justice Department to
investigate and prosecute violations of the Social Security Act or
we may use the facts in computer matching programs. Matching
programs compare our records with those of other Federal, State,
or local government agencies. All the Agencies may use matching
programs to find or prove that a person qualifies for benefits paid
for or managed by the Federal government. Another use is to
identify and collect overpayments or to collect overdue loans
under these benefits programs.

Form SSA-632-BK(XX-200X) ef (XX-200X) Draft

Page 8

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.

See Revised PRA

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 THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is 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
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.

Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate - Form SSA-632-BK

noco t p i kS

Social Security Online
www.socialsecurity.gov

Social Security Forms
Home

Questions ?

Forms Home Page

Request For Waiver Of Overpayment Recovery Or
Change In Repayment Rate - Form SSA-632-BK
When To Use this
Form

OVERPAYMENT: If SSA determines you have received
benefits to which you are not entitled we will request you
refund the overpayment. The letter we send will tell you that
if you believe you should not have to pay the money back
you should file a request for waiver of overpayment
recovery. To file a formal waiver request, you need to
complete a form SSA-632-BK, Request for Waiver of
Overpayment Recovery or Change In Repayment Rate.
RECONSIDERATION VS WAIVER: If you feel that the
overpayment amount is incorrect, or that you are not really
overpaid, you may file a form SSA-561-U2, Request for
Reconsideration. If you agree that you have been overpaid
but you feel you should not have to pay it back because you
did not cause the overpayment and you cannot afford to
refund it or repaying it would be unfair, you should file the
form SSA-632-BK, Request for Waiver of Overpayment
Recovery Or Change In Repayment Rate.
If you disagree with the overpayment decision and feel you
should not have to pay it back even if you were overpaid,
you can file both reconsideration and waiver.
EVIDENCE: When you file a request for waiver 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. You have up to
thirty days from filing the request to supply them.
The following section explains how to complete the SSA632-BK. The SSA-632-BK and supporting documents
should be either mailed or taken to your local Social
Security office. If you have further questions about the SSA632-BK, or any other Social Security matter, you may call 1800-772-1213 or contact your local SSA office.

How To Obtain the
Form

Below you will find the SSA-632-BK REQUEST FOR

http://www.ssa.gov/online/ssa-632.html[12/4/2008 2:39:50 PM]

Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate - Form SSA-632-BK

WAIVER OF OVERPAYMENT RECOVERY OR CHANGE
IN REPAYMENT RATE in Portable Document Format
(PDF) . The PDF permits you to print out a duplicate of the
original form using ANY graphics printer. The PDF was
developed by Adobe Systems, Inc. and allows the reader to
print a publication close in appearance to the original
printed version, preserving typography, columns, charts,
tables and graphics.
To read and print a PDF publication, you must have the
Adobe Acrobat Reader software installed on your PC.
Adobe Systems, Inc. permits the Social Security
Administration and other organizations to offer this software
to the public free of charge. You can download the Adobe
Acrobat Reader version suitable for your system by clicking
on this button .
After you download the Adobe Acrobat Reader, come back
to this page and download the PDF version of the SSA-632BK below. PDF files are printer independent and should
print easily on any graphics printer.
SSA-632-BK in

How To Complete the
Form

1. IDENTIFYING INFORMATION:
A. RECORD HOLDER'S NAME AND SOCIAL SECURITY
NUMBER- If you receive Social Security benefits because
of your own work or if you receive Supplemental Security
Income (SSI) payments, enter your own name and Social
Security number. If you receive Social Security benefits from
another person's work, enter that person's name and Social
Security number.
B. Names and Social Security numbers of all overpaid
individuals for whom a waiver is being requested.
2. Check as many blocks as apply and fill-in the dollar
amounts if you have checked blocks B., C., or D.
SECTION I: INFORMATION 3. through 7. Answer the
questions and fill-in the narratives in your own words
explaining those answers.
9., 10.,
10., and
12., 13.
and 13
SECTION II: FINANCIAL STATEMENT 9.,
Answer in all cases, filling in the narrative portions.
10. and 12.
11. Answer only if you are overpaid SSI.
11.

14. List your dependents who live with you regardless of
relation.
15. List for yourself and anyone listed in #14. Be sure to list

http://www.ssa.gov/online/ssa-632.html[12/4/2008 2:39:50 PM]

Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate - Form SSA-632-BK

both the balances and the income earned each month.
16. Be sure to list the vehicles and real property for both
yourself and your household members.
17. through 19. Read each question carefully, filling-in the
blanks with incomes for you, your spouse, and all other
individuals listed in #14. Make sure to list on a monthly
basis. The note on the top of page 5 tells you how to handle
weekly, bi- weekly and yearly amounts.
20. List the total household expenses, again converting to
monthly figures.
21. through 23. 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.
Sign and date- List your mailing address and the phone
number(s) 0where you can be reached.

Where To Send the
Form

For More Information

Print the PDF SSA-632-BK form on 8 1/2 x 11 inch paper,
complete and sign form, fold in thirds, insert it in a standard
size number 10 business envelope (4 1/8 x 9 1/2) and mail
to your closest Social Security office. If you are not sure
where your local office is located, try our Social Security
Office Locator service or call 1-800-772-1213.
Overpayment Information
Reconsideration Information
Form SSA-561-U2 Request For Reconsideration
Privacy Policy | Website Policies & Other Important Information | Site Map
Last reviewed or modified Monday Jan 14, 2008

http://www.ssa.gov/online/ssa-632.html[12/4/2008 2:39:50 PM]

Need

Larger Text?

Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate - Form SSA-632-BK

noco t p i kS

Social Security Online
www.socialsecurity.gov

Social Security Forms
Home

Questions ?

Forms Home Page

Request For Waiver Of Overpayment Recovery Or
Change In Repayment Rate - Form SSA-632-BK
When To Use this
Form

How To Obtain the
Form

Below you will find the SSA-632-BK REQUEST FOR

http://www.ssa.gov/online/ssa-632.html[12/4/2008 2:39:50 PM]

Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate - Form SSA-632-BK

How To Complete the
Form

14. List your dependents who live with you regardless of
relation.
15. List for yourself and anyone listed in #14. Be sure to list

http://www.ssa.gov/online/ssa-632.html[12/4/2008 2:39:50 PM]

Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate - Form SSA-632-BK

Where To Send the
Form

For More Information

http://www.ssa.gov/online/ssa-632.html[12/4/2008 2:39:50 PM]

Need

Larger Text?

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 hourse
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 212356401.

Privacy Act Statement
Collection and Use of Personal Information
Sections 204, 1631(b), and 1879, of the Social Security Act, as amended, authorize us to collect
this information. We will use the information you provide to determine whether we can waive
collection of your overpayment or adjust the amount you repay each month.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may affect the processing of this form and an accurate, timely decision of whether to
waive collection of your overpayment or to change your repayment rate.
We rarely use the information you supply us for any purpose other than to make a determination
regarding overpayment recovery and repayment rate changes. 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 ensure 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 60-0094, entitled, Recovery of
Overpayments, Accounting and Reporting/Debt Management System. Additional information
about this and other system of records notices and our programs are available online 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.

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File Title	S632(08).xft
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File Modified	2014-04-10
File Created	2009-02-23