Form SSA-632-BK

Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate

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 SSA-632-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 SSA-632-BK, or any other Social Security matter, you may call 1-800-772-1213 or contact your local SSA office.

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.

SECTION II: FINANCIAL STATEMENT 9., 10., and 13. Answer in all cases, filling in the narrative portions.

11. and 12. Answer only if you are overpaid SSI.

14. List your dependents who live with you regardless of relation.

15. List for yourself and anyone listed in #14. Be sure to list 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.

More Information:

• Overpayment Information
  
• Reconsideration Information
  
• Form SSA-561-U2 Request For Reconsideration

Below you will find the SSA-632-BK REQUEST FOR 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-632-BK below. PDF files are printer independent and should print easily on any graphics printer.

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.

SSA-632-BK in