REQUEST FOR WAIVER OF OVERPAYMENT RECOVERY

Social Security Administration

FILING INFORMATION

Date: _________________

IMPORTANT DEADLINES:
- Request waiver within 30 days of overpayment notice to prevent recovery during appeal
- Request reconsideration of overpayment amount within 60 days of notice
- File Form SSA-632 (Request for Waiver) with local SSA office

CLAIMANT INFORMATION

Claimant Name: _________________________________________________
Social Security Number: _____ - _____ - _________
Date of Birth: _________________
Address: _________________________________________________
City, State, ZIP: _________________________________________________
Phone: _________________
Email: _________________________________________________

Representative (if any):
Name: _________________________________________________
Phone: _________________
☐ Form SSA-1696 on file

OVERPAYMENT INFORMATION

Date of Overpayment Notice: _________________

Overpayment Amount: $_______________

Period of Overpayment: From _________________ to _________________

Type of Benefits Overpaid:
☐ Title II - Social Security Disability Insurance (SSDI)
☐ Title II - Retirement Benefits
☐ Title II - Survivor Benefits
☐ Title XVI - Supplemental Security Income (SSI)

Reason SSA States Overpayment Occurred:
☐ Continued to work while receiving benefits
☐ Resources exceeded SSI limit
☐ Income not properly reported
☐ Living arrangement change not reported
☐ Benefits received after death of beneficiary
☐ Disability ceased
☐ Computation error by SSA
☐ Other: _________________________________________________

TYPE OF RELIEF REQUESTED

☐ Waiver of Overpayment Recovery (Complete Sections A-E below)
- Based on: ☐ Not at fault AND ☐ Recovery would defeat purpose of Act or be against equity and good conscience

☐ Reconsideration of Overpayment Amount (if disputing amount)
- I believe the overpayment amount is incorrect because: _________________________________________________

☐ Reconsideration of Overpayment Finding (if disputing that overpayment occurred)
- I believe no overpayment occurred because: _________________________________________________

☐ Reduced Recovery Rate (if waiver denied but unable to pay full rate)
- I can afford to repay: $_______ per month

☐ Installment Agreement (if waiver not applicable)
- Proposed payment plan: $_______ per month for _______ months

SECTION A: WAIVER STANDARD

For waiver of overpayment recovery, claimant must prove BOTH:

1. The claimant was WITHOUT FAULT in causing the overpayment
AND
2. Recovery would either:
- Defeat the purpose of Title II/XVI (deprive of necessary living expenses), OR
- Be against equity and good conscience

SECTION B: WITHOUT FAULT ANALYSIS

Factors Showing Claimant Was Without Fault:

☐ Claimant relied on erroneous information from SSA
Explain: _____________________________________________________________________________
_____________________________________________________________________________

☐ Claimant did not know and could not have known of reporting requirements
Explain: _____________________________________________________________________________
_____________________________________________________________________________

☐ Claimant timely reported all required information
Date(s) reported: _________________
Method: ☐ In person ☐ Phone ☐ Mail ☐ Online
Information reported: _____________________________________________________________________________

☐ SSA made a computation or processing error
Explain: _____________________________________________________________________________
_____________________________________________________________________________

☐ Claimant lacked mental capacity to understand obligations
Explain: _____________________________________________________________________________
Supporting evidence: _____________________________________________________________________________

☐ Claimant was given incorrect advice by representative payee
Explain: _____________________________________________________________________________

☐ Other circumstances showing lack of fault
Explain: _____________________________________________________________________________
_____________________________________________________________________________

Detailed Explanation of Why Claimant Was Without Fault:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Evidence Supporting Lack of Fault:

☐ SSA records showing information was reported
☐ Copies of correspondence with SSA
☐ Phone logs or notes of conversations with SSA
☐ Medical records showing cognitive impairment
☐ Statements from third parties
☐ Other: _________________________________________________

SECTION C: DEFEAT THE PURPOSE OF THE ACT

Recovery would "defeat the purpose of the Act" if it would deprive the claimant of income and resources necessary to meet ordinary and necessary living expenses.

Current Monthly Income:

Current Monthly Expenses:

Financial Summary:

Total Monthly Income: $_______________
Total Monthly Expenses: $_______________
Monthly Surplus/(Deficit): $_______________

Assets:

Liabilities:

SECTION D: AGAINST EQUITY AND GOOD CONSCIENCE

Recovery would be "against equity and good conscience" if:

☐ Claimant changed position for the worse in reliance on the payment
Explain how claimant relied on the overpaid benefits:
_____________________________________________________________________________
_____________________________________________________________________________

Actions taken in reliance (check all that apply):
☐ Gave up other income source
☐ Made major purchase
☐ Moved/changed housing
☐ Incurred debts
☐ Declined other benefits
☐ Other: _________________________________________________

☐ Claimant relinquished a valuable right in reliance on the payment
Right relinquished: _____________________________________________________________________________

☐ Recovery would be unconscionable under the circumstances
Explain special circumstances:
_____________________________________________________________________________
_____________________________________________________________________________

SECTION E: ADDITIONAL CIRCUMSTANCES

Special Hardship Factors:

☐ Claimant is elderly (age: _____)
☐ Claimant has serious medical condition(s): _________________________________________________
☐ Claimant is sole support for dependents
☐ Claimant has fixed income with no ability to increase earnings
☐ Claimant faces eviction/foreclosure
☐ Claimant cannot afford basic necessities
☐ Other: _________________________________________________

Household Composition:

Medical Expenses and Conditions:

Current medical conditions requiring ongoing treatment:
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________

Monthly out-of-pocket medical costs: $_______________

Upcoming medical expenses: $_______________

SPECIFIC ARGUMENTS FOR WAIVER

Argument 1: Claimant Was Without Fault Because:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Argument 2: Recovery Would Defeat the Purpose of the Act Because:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

Argument 3: Recovery Would Be Against Equity and Good Conscience Because:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

ATTACHMENTS CHECKLIST

Required:
☐ Form SSA-632 (Request for Waiver of Overpayment Recovery)
☐ Copy of overpayment notice

Income Documentation:
☐ Recent benefit statements
☐ Pay stubs (last 3 months)
☐ Tax returns (last 1-2 years)
☐ Pension/retirement statements
☐ Other income documentation

Expense Documentation:
☐ Rent/mortgage statement
☐ Utility bills
☐ Medical bills
☐ Prescription receipts
☐ Insurance premium statements
☐ Loan statements
☐ Credit card statements

Asset Documentation:
☐ Bank statements (all accounts, last 3 months)
☐ Vehicle registration/loan documents
☐ Property tax statement
☐ Retirement account statements

Supporting "Without Fault":
☐ Copies of correspondence with SSA
☐ Phone logs/notes
☐ Medical records (if cognitive impairment)
☐ Third-party statements

Other:
☐ _________________________________________________
☐ _________________________________________________

SSI-SPECIFIC PROVISIONS

(If overpayment involves SSI benefits)

SSI Waiver Standards:

For SSI overpayments (42 U.S.C. § 1383(b)), waiver is granted if:
1. The overpaid individual was without fault, AND
2. Recovery would defeat the purpose of the program or be against equity and good conscience

SSI Resources:

Note: SSI resource limits: $2,000 (individual) / $3,000 (couple)

IF WAIVER IS DENIED

Option 1: Request Reconsideration

• File within 60 days of waiver denial
• Request personal conference with SSA

Option 2: Request Reduced Recovery Rate

• Complete Form SSA-634
• Demonstrate financial hardship
• Minimum recovery: $10/month or 10% of benefits

Option 3: Request Hearing

• File within 60 days
• Request hearing before ALJ

Option 4: Pay in Installments

• Negotiate payment plan with SSA
• Request affordable monthly amount

CLAIMANT CERTIFICATION

I certify that the information provided in this request is true and complete to the best of my knowledge. I understand that making false statements to the Social Security Administration may subject me to criminal penalties.

I request waiver of the overpayment in the amount of $_____________ because I was not at fault in causing the overpayment and recovery would [defeat the purpose of the Act / be against equity and good conscience / both].

Claimant Signature: _________________________________ Date: _________________

Representative Signature: _________________________________ Date: _________________

SUBMISSION INSTRUCTIONS

Submit to:
Social Security Administration
[Local Field Office Address]
_________________________________________________

Or Online: www.ssa.gov (if applicable)

By Fax: _________________

Important: Keep copies of everything submitted. Send by certified mail with return receipt or get a dated receipt if submitting in person.

FOLLOW-UP

Date Waiver Request Filed: _________________
Method: ☐ In-person ☐ Mail ☐ Fax ☐ Online
SSA Contact: _________________________________________________

Response Timeline:
- Initial response: Typically 30-60 days
- If approved: Written notice of waiver
- If denied: Written notice with appeal rights

Recovery Withheld During Appeal? ☐ Yes ☐ No
(If filed within 30 days of overpayment notice, recovery may be withheld pending decision)

This waiver request is submitted pursuant to 42 U.S.C. § 404(b) and/or 42 U.S.C. § 1383(b), and the implementing regulations at 20 C.F.R. § 404.506-404.512 and/or 20 C.F.R. § 416.550-416.572.