SSA-632

Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate

Download and Print the SSA-632

We will use your answers on this form to decide if we can waive
collection of the overpayment or change the amount you must pay us
back each month. If we can't waive collection, we may use this form to
decide how you should repay the money.

Please answer the questions on this form as completely 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.

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.

And much more...