Ssa 632 Bk Form – Fill Out and Use This PDF

Form SSA-632-BK (04-2019) UF

Page 3 of 14

I was receiving retirement benefits from Social Security.

I was receiving Social Security benefits from a parent's record.

I was receiving Social Security benefits as a widow/widower.

I was receiving Social Security benefits as a spouse.

I was receiving Supplemental Security Income (SSI) payments.

None of the above, please explain:

5.What is your reason for requesting a waiver? (Check all that apply)

	A.	The overpayment was not my fault.
	B.	I cannot afford to pay the money back.
	C.	The overpayment is unfair for other reasons.
		Please explain:
	D.	I thought I still had a disability that would make me eligible for benefits. I filed an appeal and I
		fully cooperated with Social Security.
	E.	I was age 18 and receiving SSI when the overpayment occurred.
	F.	None of the above, please explain:
6.	Are you requesting a waiver for your entire overpayment amount?						Yes	No
7.	Have you previously filed a waiver request for this overpayment?						Yes	No
	Do you have the notice for this overpayment?				Yes	No (go to 11)
8.	If you have the notice for this overpayment, please provide the date on that notice.
									(MM/DD/YYYY)

If you have the notice for this overpayment, please provide the following information: First month you were overpaid

9.Last month you were overpaid

If you were overpaid only one month, please provide the month

10.If you have the notice for this overpayment, please provide the amount of the overpayment. $

11.What was the cause of the overpayment?

(Check all that apply)

A.	I received too much income.
B.	My household received too much income.
C.	My resources were over the amount for SSI.
D.	I received help for food and shelter.
E.	I received more than one benefit payment for the same month.
F.	The Social Security Administration determined that I was no longer disabled.
G.	My marital status changed.
H.	I received workers' compensation.
I.	I was in a nursing home.
J.	I was in jail or prison.	(Options continue on next page)

Form SSA-632-BK (04-2019) UF					Page 4 of 14
11.	K.	I lived outside the U.S. for 30 consecutive days.
	L.	My immigration status changed.
	M.	Another person became entitled on the same record.
	N.	My attorney fee was not withheld from my benefits.
	O.	I was no longer a student.
	P.	I no longer had a child under age 16 or a disabled child in my care.
	Q.	I was overpaid because:
	R.	I do not know why I was overpaid.
12. A. Do you understand that you are supposed to report changes to us, for example:
		• working		• a change in resources
		• marriage		• a change in income
		• divorce		• a change in school attendance
		• moving		• any other changes that may affect your benefits
			Yes
			No, explain:

B. Is there anything that prevents you from reporting your changes to us?

Yes, please explain:	No

C. Did you tell us about the change or event that led to the overpayment?

Yes, please check one or more reasons below		No, please explain:
I called in
I sent a fax or letter
I visited a local field office
I used electronic wage reporting
Other, please explain:

Date(s) you told us about the change or event that led to the overpayment:

Do you have any documentation indicating that you told us about the change or event that led to the overpayment?

Yes, please send it with your waiver request

No, please explain:

D. Have you ever been overpaid before?

Yes (go to 12.E)

No (go to 12.F)

Form SSA-632-BK (04-2019) UF

Page 8 of 14

20. C. Are any of your dependents employed, including self-employment?

Yes (provide information below)

No (go to 21)

Name(s) of dependents:

Provide total monthly take home pay for dependent(s):

$

21.	A. Do you, your spouse, or your dependents receive support or contributions from any person,
	agency, or organization?	Yes (go to 21.B)		No (go to 22)
	B. Is the support received under a loan agreement?			Yes (go to 22)		No (go to 21.C)
	C. How much money do you, your spouse, or your dependents receive each month?
	(Show this amount on line I of question 22)
	$	Source
22.
	Income	Overpaid	SSA	Spouse of	SSA	Dependent(s) of	SSA
	(Be sure to show monthly	person's	Use	Overpaid	Use	Overpaid Person	Use
	amounts below)	income	Only	Person	Only	(Total)	Only

A. Take Home Pay (Net)

(from questions 20.A, 20.B, and 20.C)

B. Social Security Benefits (retirement,

disability, widows, students, etc.)

C. Supplemental Security Income (SSI)

D. Pension(s)	TYPE
(VA, Military, Civil
Service, Railroad, etc.)	TYPE

E. Supplemental Nutrition Assistance

Program (SNAP) Benefits

F. Income from Real Estate, Business, etc. (from questions 19.B and 19.C)

G. Room and/or Board Payments from a Person who is not a Dependent (from question 17.B). Put the amount in the overpaid person's column.

H. Child Support/Alimony

I. Other Support (from question 21.C)

J. Income from Assets

(from question 18.B)

K. Other (from any source, explain in

REMARKS on next page)

TOTALS:

Grand Total $

(Add all TOTAL blocks above)	(Options continue on next page)

Form SSA-632-BK (04-2019) UF	Page 12 of 14

Below is an authorization for the Social Security Administration to obtain your financial account information. We may need to access your financial records in order to determine if we can waive your overpayment.

IMPORTANT: If the overpaid individual is a minor child, a parent or legal guardian must complete and sign the form on the child's behalf. If a court has assigned a legal guardian to an adult individual, the legal guardian must complete and sign the form. Adults who do not have a court appointed legal guardian must complete and sign the form, even if they have a representative payee.

AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN ACCOUNT RECORDS FROM A FINANCIAL INSTITUTION AND REQUEST FOR RECORDS

Please review the following, make selection, and sign below:

Iunderstand:

•I have the right to revoke this authorization at any time before any records are disclosed;

•The Social Security Administration may request all records about me from any financial institution;

•Any information obtained will be kept confidential;

•I have the right to obtain a copy of the record which the financial institution keeps concerning the instances when it has disclosed records to a government authority unless the records were disclosed because of a court order;

•This authorization is not required as a condition of doing business with any financial institution.

•The Social Security Administration will request records to determine the ability to repay an overpayment in conjunction with a waiver determination;

•Failing to provide or revoking my authorization may result in the Social Security Administration determining, on that basis, that adjustment or recovery of the overpayment will not deprive me of funds to pay my bills for food, clothing, housing, medical care, or other necessary expenses;

•This authorization is in effect until the earliest of: 1) a final decision on whether adjustment or recovery of my overpayment would deprive me of funds to pay my bills for food, clothing, housing, medical care, or other necessary expenses; or 2) my revocation of this authorization in written notification to the Social Security Administration.

I authorize any custodian of records at any financial institution to disclose to the Social Security Administration any records about my financial business or that of the person named above whom I legally represent or whose benefits I manage.

I do not authorize any custodian of records at any financial institution to disclose to the Social Security Administration any records about my financial business or that of the person named above whom I legally represent or whose benefits I manage. I understand that if I do not give permission to obtain financial records or if I cancel my permission, SSA may not approve my waiver request.

Customer's Signature/Authorization	Mailing Address	Date
Legal Representative's	Legal Representative's Mailing Address	Date
Signature/Authorization

Form SSA-632-BK (04-2019) UF

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Privacy Act Statement

Collection and Use of Personal Information

Sections 204, 1631, and 1879 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on your overpayment waiver request.

We will use the information to make a waiver determination and to obtain your financial account information. We may also share your information for the following purposes: called routine uses:

•To student volunteers and other worker, who technically do not have the status of Federal employees, when they are performing work for Social Security Administration (SSA) as authorized by law, and they need access to personally identifiable information in SSA records in order to perform their assigned agency functions; and

•To third party contacts such as private collection agencies and credit reporting agencies under contract with SSA and other agencies, including the Veterans Administration, the Armed Forces, the Department of the Treasury, and State motor vehicle agencies, for the purposes of their assisting SSA in recovering program debt.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0094, entitled Recovery of Overpayments, Accounting and Reporting/Debt Management System, as published in the Federal Register (FR) on August 23, 2005, at 70 FR 49354; 60-0231, entitled Financial Transactions of SSA Accounting and Finance Offices, as published in the FR on January 11, 2006, at 71 FR 1849; and

60-0320, entitled Electronic Disability Claims File, as published in the FR on July 25, 2006, at 71 FR 42159. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/ privacy.

- This information collection meets the clearance 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 120 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-0001. Send only comments relating to our time estimate to this address, not the completed form.