Form SSA-632-BK Request for Waiver of Overpayment Recovery or Change in Repayment Rate

What Is Form SSA-632-BK?

Form SSA-632-BK, Request for Waiver of Overpayment Recovery or Change in Repayment Rate is a form used for overpayments. An overpayment occurs when the Social Security Administration (SSA) pays you more than you should have been paid. The SSA will notify you about it and inform you why an overpayment happened and how you will be able to pay them back. They will also let you know how to ask them to reconsider their decision, to let you pay the money back at a different rate, or to waive the overpayment. If you agree that the overpayment happened and you are willing to pay the money back, but for some reason cannot afford to pay it back at the rate the SSA asks of you, or you feel you should not pay it back because the overpayment was not your mistake, you should file the SSA-632 Form.

The latest version of the form - also known as the SSA Form 632-BK - was released by the SSA in January 2018 with all previous editions obsolete. An SSA-632 fillable form is available for download and digital filing below.

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Form SSA-632-BK (01-2018) UF
Discontinue Prior Editions
Page 1 of 9
Social Security Administration
OMB No. 0960-0037
Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate
FOR SSA USE ONLY
ROAR Input
Yes
We will use your answers on this form to decide if we can
No
waive collection of the overpayment or change the
Input Date
amount you must pay us back each month. If we can't
waive collection, we may use this form to decide how you
Waiver
Approval
should repay the money.
Denial
SSI
Yes
No
Please answer the questions on this form as completely
AMT OF OP $
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
PERIOD (DATES) OF OP
the questions as they apply to that person.
1.
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 or her Social Security Number(s):
2.
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.
B.
I cannot afford to use all of my monthly benefit to pay back the overpayment. However I can
afford to have $
withheld each month.
C.
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.
D.
I am receiving SSI payments. I want to pay back $
each month instead of
paying 10% of my total income.
Form SSA-632-BK (01-2018) UF
Discontinue Prior Editions
Page 1 of 9
Social Security Administration
OMB No. 0960-0037
Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate
FOR SSA USE ONLY
ROAR Input
Yes
We will use your answers on this form to decide if we can
No
waive collection of the overpayment or change the
Input Date
amount you must pay us back each month. If we can't
waive collection, we may use this form to decide how you
Waiver
Approval
should repay the money.
Denial
SSI
Yes
No
Please answer the questions on this form as completely
AMT OF OP $
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
PERIOD (DATES) OF OP
the questions as they apply to that person.
1.
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 or her Social Security Number(s):
2.
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.
B.
I cannot afford to use all of my monthly benefit to pay back the overpayment. However I can
afford to have $
withheld each month.
C.
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.
D.
I am receiving SSI payments. I want to pay back $
each month instead of
paying 10% of my total income.
Form SSA-632-BK (01-2018) UF
Page 2 of 9
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:
A. Was the overpaid person living with you when he/she was overpaid?
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
Yes
No
didn't you tell us?
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
Yes
No
change, did you contact us again?
7.
A. Have we ever overpaid you before?
Yes
No
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 (01-2018) UF
Page 3 of 9
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
2 or 3 recent utility, medical, charge card,
and insurance bills
Savings Passbooks
Canceled checks
Pay Stubs
Similar documents for your spouse or
Your most recent Tax Return
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.
Yes
Amount:
A. Do you now have any of the overpaid checks or money in
your possession (or in a savings or other type of account)?
Return this
No
amount to SSA
B. Did you have any of the overpaid checks or money in your
Amount:
Yes
possession (or in a savings or other type of account) at the
Answer Question 9.
No
time you received the overpayment notice?
9. Explain why you believe you should not have to return this amount.
ANSWER 10 AND 11 ONLY IF THE OVERPAYMENT IS SUPPLEMENTAL SECURITY INCOME
(SSI) PAYMENTS. IF NOT, SKIP TO 12.
10.
A. Did you lend or give away any property or cash after notification
Yes (Answer Part B)
of the overpayment?
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
Yes (Answer Part B)
(other than earnings) after notification of this overpayment?
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
Yes (Answer B and C and See note below)
such as Supplemental Security Income
(SSI) payments?
No
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 (01-2018) UF
Page 4 of 9
Members Of Household
13. List any person (child, parent, friend, etc.) who depends on you for support AND who lives
with you.
RELATIONSHIP
NAME
AGE
(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?
SHOW THE INCOME (interest,
PER
BALANCE OR
dividends) EARNED EACH
TYPE OF ASSET
OWNER
VALUE
MONTH
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)
$
$
Enter the "Per Month" total
TOTALS
$
$
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.
PRESENT
LOAN BALANCE
MAIN PURPOSE
OWNER
YEAR/MAKE/MODEL
VALUE
(if any)
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.
MARKET
LOAN BALANCE
USAGE-INCOME
OWNER
DESCRIPTION
VALUE
(if any)
(rent etc.)
$
$
$
$
$
$
$
$
Form SSA-632-BK (01-2018) UF
Page 5 of 9
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.
A. Are you employed?
YES (Provide information below)
NO (Skip to B)
Employer name, address, and phone: (Write "self" if self-employed)
Monthly pay before
$
deduction (Gross)
Monthly TAKE-
$
HOME pay ( NET )
B. Is your spouse employed?
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)
YES
Name(s)
C. Is any other person listed in
Question 13 employed?
NO (Go to Question 17)
Employer(s) name, address, and phone: (Write "self" if self-employed)
Monthly pay before
$
deduction (Gross)
Monthly TAKE-
$
HOME pay (NET)
17.
YES (Answer B)
A. Do you, your spouse or any dependent member of your household
receive support or contributions from any person or organization?
NO (Go to question 18)
B. How much money is received each month?
$
SOURCE
(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.
OTHER
SSA USE
18.
INCOME FROM #16 AND #17 ABOVE
/
/
/
YOURS
SPOUSE'S
\
\
\
HOUSEHOLD
AND OTHER INCOME TO YOUR HOUSEHOLD
ONLY
MEMBERS
A. TAKE HOME Pay (Net)
$
$
$
(From #16 A, B, C, above)
B. Social Security Benefits
C. Supplemental Security Income (SSI)
D. Pension(s)
TYPE
(VA, Military,
Civil Service,
TYPE
Railroad, etc.)
E. Public Assistance
TYPE
(Other than SSI)
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)

Download Form SSA-632-BK Request for Waiver of Overpayment Recovery or Change in Repayment Rate

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How to Fill out SSA-632-BK?

  1. Name the individual on whose record the overpayment occurred, this person's social security number, and the names of overpaid persons making this request along with their social security numbers;
  2. Check the applicable boxes:
    • The overpayment was not your fault, you cannot pay the money back and/or it is unfair for another reason;
    • You cannot use all of your monthly benefits to pay back the overpayment, but you can have a certain amount of money withheld each month;
    • You no longer receive Supplement Security Income (SSI) payments, and you want to pay back a certain sum of money each month instead of paying back all at once;
    • You receive SSI payments, and you want to pay back a certain amount of money each month instead of paying 10% of your total income.
  3. State if you receive the overpaid benefits as a representative payee to use it for the beneficiary. Write down the beneficiary's name and current address and state how the overpaid benefits were used.
  4. If the SSA is asking you to repay someone else's overpayment, state if the overpaid person was living with you when the overpayment occurred, if you received the overpaid money, and explain what you know about the overpayment and why it was not your fault.
  5. Answer why you think you were due to the overpaid money and explain why you did not you tell the SSA about the overpayment. If you did, state when and where you did and if you contacted the SSA again.
  6. If the overpayment happened before, indicate the social security number it happened on and the reason for it.
  7. State if you have any overpaid checks or money in your possession now or if you had any when you received the overpayment notice.
  8. Explain why you believe you do not have to return this money.
  9. Answer if you lent, gave away, received or sold any property or cash after receiving the overpayment notice and describe it.
  10. State if you are now receiving cash public assistance.
  11. List people who depend on you for financial support and live with you.
  12. Indicate how much money you have readily available and describe every type of asset. Show the income earned each month and list vehicles and real estate you and your household members have in possession.
  13. Provide your own and your household members' employment information, write down the employer's name, address, and phone.
  14. State if you or any other household member receive contribution or support from any organization or individual.
  15. Fully describe all the income to your household.
  16. Identify all monthly household expenses.
  17. Compare your monthly income and monthly expenses and explain how you are paying your bills if your expenses are more than your income.
  18. Tell the SSA about your available funds and financial expectations if you expect your financial situation to change for the better or worse in the next 6 months.
  19. Affirm that all the information on this form is correct and true.
  20. Sign the form and provide all necessary contact information.

Form SSA-632-BK Instructions

Instructions for SSA-632-BK are as follows:

  1. Answer all the questions as fully and carefully as you can. If you are completing this form for someone else, answer the questions as they apply to that individual.
  2. You are required to complete the section concerning your financial statement if you want the SSA either to change the rate at which they asked you to repay the money or to waive the collection of the overpayment.
  3. Prepare documents and their copies to support your statements and money amounts in the form.
  4. If you need to add any information, you can use the «Remarks» section on page 7.
  5. If you do not understand questions on the form, take the form to your local social security office and ask them to explain it to you.

Form SSA-632-BK FAQ

Where to Mail SSA-632-BK?

When you download, print and complete a paper version of the form you can send it to your local social security office. If you have any additional questions, you can call the SSA at 1-800-772-1213.

What Does "Readily Available" Mean on Form SSA-632-BK?

When you answer the question 14 in the Section «Assets - Things You Have and Own», you are required to state how much money do you and person(s) indicated in question 13 have as cash on hand, in a checking account, or readily available. In this context readily available means funds that are easily and promptly accessible for immediate use.

How Long Does Form 632 Averagely Take to Be Processed by the SSA?

Generally, it takes the SSA about six weeks to process your Social Security appeal Form SSA-632 and get back to you.

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