Enter SSA Agency Code: ZSSA directly above Agency Claim No. Show the Social Security Number (SSN) on which the overpayment occurred in the upper rind hand corner of the form.

1

Insert the number that your agency uses to identify the claim. Please record the number at the top of all subsequent pages of the CCLR (fillable PDF will populate this on the top of all pages).

2

Civil Suit- Leave blank. The ARC, MOS will insert the date the CCLR is sent to the CIF or to Central Justice in Washington, DC.

Bankruptcy- Insert current date.

3a

Civil Suit - Show “Social Security Administration” and the complete address of the appropriate Regional Office (RO).

Bankruptcy - Show “Social Security Administration” and the mailing address for the PC of record.

3b

Show “Social Security Administration”

3c

Civil Suit - Show the date of the last contact (by phone or mail) with the debtor.

Bankruptcy - Show the name and telephone number of a PSC contact to answer questions relating to the claim.

3d

Leave blank. This information will be completed by the ARC, MOS

3e

Insert the total amount of the claim (same amount placed in 9a.)

4

Show the debtors’ full name(s), current address(es), and SSN.

If a non-beneficiary and SSN unknown, attempt to secure via various systems queries. If unable to obtain, click the “Unknown” Box.

5

Show the date (month/day/year) the statute of limitations will bar recovery by civil suit. For example, a debtor was repaying by monthly installments. The last payment was made on June 10, 1991. Recovery by civil suit would not be barred until June 9, 1997 (within 6 years from payment default). For an explanation of the statute of limitations, see GN 02215.150B.2. Show the basis for the date given by providing the date of the last payment made.

6

Not applicable to SSA debts; leave blank.

7

Civil Suit - Show the date of the last contact (by phone or mail) with the debtor.

Bankruptcy - If debtor is in nonpay, follow the above civil suit instructions. If benefit withholding was in effect, show, “the overpayment was being recovered by withholding (or partially withholding) the debtor's monthly benefit check. Recovery stopped due to the bankruptcy filing.”

8a

DOJ Concurrence for Compromise, Suspension, or Termination - Check appropriate block when we seek DOJ approval to compromise or to discontinue collection efforts.

8b

Check one of the following boxes:

• Enforced Collection - Civil suit referral of a debt of $3,000 or more; or

• Program Enforcement - Civil suit referral of a debt less than $3,000 but referral is important to a significant enforcement policy. For example, referral of a $200 debt because the debtor is a Federal employee.

8c

Fill in the Bankruptcy Court No. and the Filing Date. Check the appropriate box to indicate chapter 7, 11, 12, or 13.

9a

Only enter the “Total Principal Due” amount, the form will auto fill the “Total Amount of Claim”.

When the amount relates to misused or conserved funds rather than an overpayment, show “misused funds” or “conserved benefits,” as applicable, after the amount. If the debtor is liable for repayment of overpayments on more than one record, show the combined amount ($6,900 when the debtor was overpaid $900 in disability on his or her own record, and also overpaid $6,000 as representative payee for children on deceased spouse's record).

9b-9c

Not applicable to SSA debts; leave blank.

9d

Choose the “Yes” Option and enter a dollar amount equal to 80 percent of the debt.

10

Choose the “Statue or Regulation (provide citation)” option and annotate “20 CFR 401-422.”

11

Civil suit - Show the name and telephone numbers of the ARC, MOS (or PSC) contact to answer any questions relating to the claim.

Bankruptcy - Show the name and telephone number of a PSC contact to answer questions relating to the claim.

12a

Choose the “Individual” option. For SSA’s purpose, the debt will always be an Individual.

12b

Indicate the type of debtor – Primary, Co-Debtor, Co-Signer, or Guarantor. IMPORTANT: If the representative payee is liable for repayment of the debt because he or she did not use the monies received for the beneficiary, the representative payee is the overpaid person. In such situations, complete the CCLR in its entirety only for the representative payee.

13a

Show the debtor's full name and address.

13b

Insert the debtor’s complete 9-Digit SSN and the beneficiary identification code (BIC).

If the debtor is married but the spouse is not a co-debtor (equally liable for the same debt), use the CCLR Supplementary Data Sheet to furnish the information in blocks 12-21 for the spouse. If any of the information is unavailable, show, “Unknown” in the appropriate blocks. Prepare a second CCLR only if the spouse is overpaid in his/her own right.

14

Show the debtor's present phone number, including the area code. Show debtor's work phone number including the area code. If not available, show “Unknown.”

15

Show debtor's date of birth and if necessary the relationship to the primary debtor.

16

Show any other name(s) (aliases) used by the debtor. If no aliases used, show “Not Applicable.”

17

Basis of Liability: (Individual debtors) Insert facts giving rise to any liability for this debt, including any family relationship to the primary debtor (if applicable). Include any applicable statute that relates to the basis of the liability. If the person was a representative payee, explain that they were at fault in causing the overpayment.

18

Not applicable to SSA debts; leave blank.

19

Provide the debtor's home address if not filled out in box 4.

20

Not applicable to SSA debts; leave blank.

21

Is Debtor Represented by an Attorney: Check “Yes” or “No” to indicate if the debtor is represented by an attorney. If “Yes”, provide contact information for the attorney.

22

Show the debtor's job title or description. If not available, show “Unknown.”

23

Show the name and address of the debtor's current employer or self-employment activity. If not available, show “Unknown”.

24

Insert debtor's salary, indicate whether gross or net and how often paid. For a Federal employee debtor whose salary cannot be obtained explain on the CCLR Supplementary Data Sheet that the debtor is currently a Federal employee, so we are forwarding the matter for such further action as the U.S. Attorney deems necessary.

25

Provide information on any real estate or other property (cars, boats, vacation homes) the debtor owns or is buying. If available, include the value and location of any property.

26

Show, “Not Applicable.”

27

Use whatever information is currently available. Use the CCLR Supplementary Data Sheet to explain the evidence that discloses the present or likely future availability of assets or income from which a substantial sum may be obtained by enforced collection proceedings against the debtor. (See GN 02215.150B.5.) Include a copy of an SSA-632-BK (Request for Waiver of Overpayment Recovery or Change in Repayment Rate) completed by the debtor whenever possible. An SSA-632-BK completed in connection with waiver development within the past 6 months is acceptable.

If an SSA-632-BK is unavailable, provide an explanation of the person's earnings as shown on the SEQY or DEQY.

For federally employed debtors where the debtor's ability to repay is not established (GN 02215.150B.5), explain why the debt is being referred. For example, the debtor is overpaid $10,000 but refuses to divulge his financial situation and the FO investigation does not conclusively establish ability to repay. In conserved benefit situations, furnish the financial condition of the former payee, if available. Where this information is not available, show “Not Applicable - conserved benefits involved.”

28-31

Not applicable to SSA debts; leave blank.

32

Add additional contact information for administrative units, collections units, and any other appropriate units in your agency that would assist DOJ in its collection efforts.

33

Provide details on the program that suffered a loss, (RIB, DIB, or Auxiliary).

34

Show the date of the last refund request, the debtor's response, if any, the date (mo/yr) of the response and how the response was made (by letter, phone, or personal visit to FO). If the debtor did not respond to the last demand, show “No response.”

35

Briefly explain when (date) and how (final notice requesting refund, FO or Debtor Contact Section (DCS) personal contact) the possibility of a compromise settlement was mentioned. If applicable, include the amount of any offer and the date it was made. Explain the final decision made on any offer (accepted offer of $XX.XX, but payment not received, or reason for rejection of offer). If debtor did not make an offer, show “Debtor did not offer compromise.”

36

Insert data on actions taken to collect this claim up to this point.

37

Show all payments received to date including the date of the last payment.

38

Provide a brief explanation if the referral was previously submitted to DOJ for litigation.

39

Not applicable to SSA debts; leave blank.

40

Briefly explain the efforts to collect the overpayment and state that all usual means of collection (notices and personal contact) has been exhausted. Attach copies of all available notices requesting refund, photocopies of reports of contact and correspondence from the debtor (an attorney, if applicable), and replies to such correspondence. For conserved benefit cases, list all FO or DCS contacts and all PSC requests for transfer of funds.

41

CCLR Supplementary Data Sheet

Agency CCLR Submission Checklist

Check all blocks under “General”. Put an asterisk (*) beside the “Credit Report” block and annotate, “See CCLR Supplementary Data Sheet.” Do not check any boxes under “Additional information for Foreclosures”.