Form SSA-2032-BK "Request for Waiver of Special Veterans Benefits (Svb) Overpayment Recovery or Change in Repayment Rate"

What Is Form SSA-2032-BK?

This is a legal form that was released by the U.S. Social Security Administration on April 1, 2017 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2017;
  • The latest available edition released by the U.S. Social Security Administration;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form SSA-2032-BK by clicking the link below or browse more documents and templates provided by the U.S. Social Security Administration.

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Download Form SSA-2032-BK "Request for Waiver of Special Veterans Benefits (Svb) Overpayment Recovery or Change in Repayment Rate"

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Form SSA-2032-BK (04-2017)
Discontinue Previous Editions
Page 1 of 11
Social Security Administration
OMB No. 0960-0698
Request for Waiver of Special Veterans Benefits (SVB)
Overpayment Recovery or Change in Repayment Rate
We will use your answers on this form to decide
FOR SSA USE ONLY
if we can waive collection of the overpayment or
change the amount you must pay us back each month.
Input Date
If we can’t waive collection, we may use this form to
Waiver Approval
decide how you should repay the money.
Denial
Please answer the questions on this form as completely
Amt of O/P (Show in U.S. $)
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.
Period (Dates) of O/P
If you need more room for responses, use “REMARKS” on
MM/YYYY to MM/YYYY
page 9.
1. Name of Beneficiary
Social Security Number
-
-
Name of Representative Payee (if applicable)
Social Security Number
-
-
If representative payee is requesting waiver or change in repayment rate, answer 1.A. and 1.B.
and continue:
A. Were all or some of the overpaid SVB payments received used for the beneficiary?
If yes, answer B. below.
Yes
If no, skip to Question 2.
No
Address of the beneficiary
B. How were the overpaid benefits used?
2. If you are requesting waiver of the overpayment, please check block A. if it applies to you:
A. The SVB overpayment was not my fault and I cannot afford to pay the money back and/or it is
unfair to make me pay the money back for some other reason. (Explain in “REMARKS” on
page 9.)
If you are currently receiving SVB, please check block B. if it applies to you:
B. I am receiving SVB, but cannot afford to have the amount of my monthly benefit (or an amount
equal to 10% of the maximum SVB monthly payment amount, whichever is less) withheld from
my SVB to pay back the overpaid benefits I received. Instead, I want $
(cannot
be less than $1) withheld each month from my SVB to pay back the overpayment.
If you are no longer receiving SVB, check block C. if it applies to you:
C. I want to pay back $
(cannot be less than $10) each month instead of repaying
the SVB overpayment at once.
Form SSA-2032-BK (04-2017)
Discontinue Previous Editions
Page 1 of 11
Social Security Administration
OMB No. 0960-0698
Request for Waiver of Special Veterans Benefits (SVB)
Overpayment Recovery or Change in Repayment Rate
We will use your answers on this form to decide
FOR SSA USE ONLY
if we can waive collection of the overpayment or
change the amount you must pay us back each month.
Input Date
If we can’t waive collection, we may use this form to
Waiver Approval
decide how you should repay the money.
Denial
Please answer the questions on this form as completely
Amt of O/P (Show in U.S. $)
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.
Period (Dates) of O/P
If you need more room for responses, use “REMARKS” on
MM/YYYY to MM/YYYY
page 9.
1. Name of Beneficiary
Social Security Number
-
-
Name of Representative Payee (if applicable)
Social Security Number
-
-
If representative payee is requesting waiver or change in repayment rate, answer 1.A. and 1.B.
and continue:
A. Were all or some of the overpaid SVB payments received used for the beneficiary?
If yes, answer B. below.
Yes
If no, skip to Question 2.
No
Address of the beneficiary
B. How were the overpaid benefits used?
2. If you are requesting waiver of the overpayment, please check block A. if it applies to you:
A. The SVB overpayment was not my fault and I cannot afford to pay the money back and/or it is
unfair to make me pay the money back for some other reason. (Explain in “REMARKS” on
page 9.)
If you are currently receiving SVB, please check block B. if it applies to you:
B. I am receiving SVB, but cannot afford to have the amount of my monthly benefit (or an amount
equal to 10% of the maximum SVB monthly payment amount, whichever is less) withheld from
my SVB to pay back the overpaid benefits I received. Instead, I want $
(cannot
be less than $1) withheld each month from my SVB to pay back the overpayment.
If you are no longer receiving SVB, check block C. if it applies to you:
C. I want to pay back $
(cannot be less than $10) each month instead of repaying
the SVB overpayment at once.
Form SSA-2032-BK (04-2017)
Page 2 of 11
SECTION 1 - INFORMATION ABOUT RECEIVING THE OVERPAYMENT
3. 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?
4. A. Did you tell us about the change or event that made you overpaid?
If yes, complete 4.B. and, if applicable, 4.C. below.
Yes
No
If no, why 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, with whom did you
talk, and what was said?
C. If you did not hear from us after your report, and/or the amount or payment of your SVB did not
change, did you contact us again?
If yes, what were you told would happen?
Yes
No
5. A. Have we ever overpaid you before?
Yes
If yes, complete B. and C. below
No
If no, skip to Question 6.
B. If yes, on what Social Security number were you overpaid?
C. 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.
SECTION 2 - YOUR FINANCIAL STATEMENT
You must 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, or we may ask you to send them to us.
Examples of documents 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
You can express amounts in local currency. If U.S. currency is shown, show whole dollar amounts only –
round any cents to the nearest dollar.
Form SSA-2032-BK (04-2017)
Page 3 of 11
6. A. Do you now have any of the overpaid benefits in your possession (or in a savings or other type
of account)?
Yes
Amount:
Please contact SSA personnel as shown in “IMPORTANT”
below to return these funds to SSA.
No
B. Did you have any of the overpaid benefits in your possession (or in a savings or other type of account)
when you received the overpayment notice?
Yes
Amount
Please complete Question 7 below.
No
7. Explain why you believe you should not have to return this amount.
8. A. Are you now receiving U.S. Federal, state or local cash public assistance such as Supplemental
Security Income (SSI) payments?
Yes
If yes, answer B. and C. See “IMPORTANT” below.
No
B. Name or kind of public assistance
C. Claim number
IMPORTANT: If you answered “Yes” to Question 8, DO NOT answer any more questions on this form. Go
to the spaces provided on page 10 at the end of the form for signature and date. Sign and date the form,
and provide your address and a telephone number. Bring or mail this form (and any papers that show you
receive U.S. Federal, state or local public assistance, if this is the case) to your local Social Security office
or to the U.S. Embassy, SSA, 1201 Roxas Blvd., Ermita 0930 Manila as soon as possible.
MEMBERS OF HOUSEHOLD – DO NOT Complete if Answer to 8.A. was “Yes”
9. List any person (child, parent, friend, etc.) who depends on you for support and who lives with you.
Relationship
Name
Age
(If none, say why the person is your dependent)
Form SSA-2032-BK (04-2017)
Page 4 of 11
ASSETS - THINGS YOU HAVE AND OWN –
DO NOT Complete if Answer to 8.A. was “Yes”
10. A. How much money do you and any person(s) listed in Question 9 above have as cash on hand, in a
checking account, or otherwise readily available?
Amount:
B. If there is an amount of cash on hand or in checking accounts shown in Question 10.A., is it being
held for a special purpose?
No amount on hand
No (Money available for any use.)
Yes (Explain on line below.)
C. 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, dividends)
Earned Each Month. (If
Type of Asset
Owner
Balance or Value
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
D. Is there any reason you CANNOT convert to cash the “Balance or Value” of any financial asset
shown in Question 10.C.?
Yes
If yes, explain on line below.
No
Form SSA-2032-BK (04-2017)
Page 5 of 11
11. A. If you or a member of your household owns a car, van, truck, camper, motorcycle or any other
vehicle or a boat, (other than a vehicle used for family or work transportation) list below.
Year,
Loan Balance (if
Main Purpose for
Owner
Present Value
Make/Model
any)
Use
B. If you or a member of your household owns any real estate (buildings or land), OTHER than where
you live; or owns or has an interest in any business, property or valuables, describe below.
Loan Balance (if
Usage-Income
Owner
Description
Market Value
any)
(rent, etc.)
C. Is there any reason you CANNOT SELL or otherwise convert to cash any of the assets shown in
Question 11.A. and 11.B.?
Yes
If yes, explain on line below.
No
MONTHLY HOUSEHOLD INCOME
BE SURE TO SHOW MONTHLY AMOUNTS BELOW. 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.
Also, enter monthly TAKE HOME amounts on line A of Question 14.
12. A. Are you employed?
Yes
If yes, provide information below.
No
If no, skip to 12.B.
Employer Name
Employer Address
Employer Telephone Number
If self-employed write “Self”
Monthly pay before any deduction: (Gross)
Monthly TAKE HOME pay (Net)