DSS Form 2627A "Repayment Agreement and Acknowledgment of Debt" - South Carolina

What Is DSS Form 2627A?

This is a legal form that was released by the South Carolina Department of Social Services - a government authority operating within South Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2010;
  • The latest edition provided by the South Carolina Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of DSS Form 2627A by clicking the link below or browse more documents and templates provided by the South Carolina Department of Social Services.

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Download DSS Form 2627A "Repayment Agreement and Acknowledgment of Debt" - South Carolina

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South Carolina Department of Social Services
Family Independence (FI) and Supplemental Nutrition Assistance Program (SNAP)/Benefit Integrity
REPAYMENT AGREEMENT AND ACKNOWLEDGMENT OF DEBT
Case Name:
Case No:
County:
Select County ...
Social Security Number (SSN):
Overpayment Amount:
Seq. Class
$
in the Family Independence (FI) Program for the period of
to
.
$
in the SNAP for the period of
to
.
$
in the Supportive Services (SS) Program for the period of
to
.
I hereby acknowledge my debt owed to the South Carolina Department of Social Services (SCDSS) in the
amount shown above. I agree to make payments in the manner indicated below:
If I currently receive benefits, I understand that my benefits are being reduced each month to repay my debt by
10% or $10, whichever is greater, for the
Program(s), effective
.
20% or $20, whichever is greater, for overpayments classified as intentional program violation for fraud in the SNAP
Program, effective
.
I understand that this reduction will continue each month that I receive benefits until my debt (including other
outstanding claim sequences in the same program) is paid in full. I understand that if I stop receiving benefits
before my debt is paid in full, I must make payments by one of the methods listed below.
I agree to increase the percentage by which my benefits are reduced each month to:
% or $
for SNAP, effective
.
% or $
for FI, effective
.
I understand that this reduction will continue each month that I receive benefits until my debt (including other
outstanding claim sequences in the same program) is paid in full or until I terminate this agreement with the Benefit
Integrity Claims Specialist. I understand that if I stop receiving benefits before my debt is paid in full, I must
make payments by one of the methods listed below.
I agree to make monthly payments by cash, money order or certified check in the amount of $
beginning
(month)
(day)
(year) or effective the month of my case closure and continuing by
the
of each month until debt is paid in full. I understand that these payments may be applied to any
outstanding FI or SNAP debt for which I am responsible for payment.
I understand that I can repay my SNAP debt with benefits in my EBT account. I understand that using my EBT
account as a method of payment is completely voluntary. I understand that this agreement to repay my debt by using
benefits in my EBT account will remain valid until my outstanding SNAP debt is paid in full or until I terminate the
agreement, whichever occurs first. I understand that a request to end the process of monthly payments from my
EBT account must be in writing and must be submitted to the Benefit Integrity Claims Specialist (BICS) for
Select County ...
County.
I agree to make a one time payment from my EBT account in the amount of $
.
I agree to make monthly payments from my EBT account in the amount of $
.
I understand that SCDSS may use other collection methods to secure repayment of my debt and I hereby
consent to the use of this Agreement as evidence against me for the repayment of my debt(s) above and any
situation, including criminal and civil actions, relating to and/or involving the amounts owed. I also understand
SCDSS may authorize the Internal Revenue Service (IRS) and/or the South Carolina Department of Revenue,
and/or SC Education Lottery to withhold any refund due to me to repay my debt if I do not make payments as
scheduled above.
I understand that this agreement does not preclude criminal prosecution or civil action, even if all outstanding
balances are paid, if it is determined that I have committed an intentional program violation classified under
state and federal statutes as fraud.
Signature of Debtor:
Date:
Signature of BICS:
Date:
DSS Form 2627A (MAY 10) Edition of NOV 01 is obsolete.
Reset
South Carolina Department of Social Services
Family Independence (FI) and Supplemental Nutrition Assistance Program (SNAP)/Benefit Integrity
REPAYMENT AGREEMENT AND ACKNOWLEDGMENT OF DEBT
Case Name:
Case No:
County:
Select County ...
Social Security Number (SSN):
Overpayment Amount:
Seq. Class
$
in the Family Independence (FI) Program for the period of
to
.
$
in the SNAP for the period of
to
.
$
in the Supportive Services (SS) Program for the period of
to
.
I hereby acknowledge my debt owed to the South Carolina Department of Social Services (SCDSS) in the
amount shown above. I agree to make payments in the manner indicated below:
If I currently receive benefits, I understand that my benefits are being reduced each month to repay my debt by
10% or $10, whichever is greater, for the
Program(s), effective
.
20% or $20, whichever is greater, for overpayments classified as intentional program violation for fraud in the SNAP
Program, effective
.
I understand that this reduction will continue each month that I receive benefits until my debt (including other
outstanding claim sequences in the same program) is paid in full. I understand that if I stop receiving benefits
before my debt is paid in full, I must make payments by one of the methods listed below.
I agree to increase the percentage by which my benefits are reduced each month to:
% or $
for SNAP, effective
.
% or $
for FI, effective
.
I understand that this reduction will continue each month that I receive benefits until my debt (including other
outstanding claim sequences in the same program) is paid in full or until I terminate this agreement with the Benefit
Integrity Claims Specialist. I understand that if I stop receiving benefits before my debt is paid in full, I must
make payments by one of the methods listed below.
I agree to make monthly payments by cash, money order or certified check in the amount of $
beginning
(month)
(day)
(year) or effective the month of my case closure and continuing by
the
of each month until debt is paid in full. I understand that these payments may be applied to any
outstanding FI or SNAP debt for which I am responsible for payment.
I understand that I can repay my SNAP debt with benefits in my EBT account. I understand that using my EBT
account as a method of payment is completely voluntary. I understand that this agreement to repay my debt by using
benefits in my EBT account will remain valid until my outstanding SNAP debt is paid in full or until I terminate the
agreement, whichever occurs first. I understand that a request to end the process of monthly payments from my
EBT account must be in writing and must be submitted to the Benefit Integrity Claims Specialist (BICS) for
Select County ...
County.
I agree to make a one time payment from my EBT account in the amount of $
.
I agree to make monthly payments from my EBT account in the amount of $
.
I understand that SCDSS may use other collection methods to secure repayment of my debt and I hereby
consent to the use of this Agreement as evidence against me for the repayment of my debt(s) above and any
situation, including criminal and civil actions, relating to and/or involving the amounts owed. I also understand
SCDSS may authorize the Internal Revenue Service (IRS) and/or the South Carolina Department of Revenue,
and/or SC Education Lottery to withhold any refund due to me to repay my debt if I do not make payments as
scheduled above.
I understand that this agreement does not preclude criminal prosecution or civil action, even if all outstanding
balances are paid, if it is determined that I have committed an intentional program violation classified under
state and federal statutes as fraud.
Signature of Debtor:
Date:
Signature of BICS:
Date:
DSS Form 2627A (MAY 10) Edition of NOV 01 is obsolete.