TN 12 (04-09)

A. Policy for completing the SSA-632-BK

1. Uses for the SSA-632-BK

The SSA-632-BK is used to:

1. Obtain sufficient information about fault and financial circumstances to make a waiver determination.

2. Request a change in the rate of adjustment to less than the 10 percent rate.

3. Determine ability to repay for certain compromise offers.

4. Refer a claim for recovery by civil suit.

2. SSA-632-BK unnecessary

It is unnecessary to complete the SSA-632-BK if there is:

1. Equivalent information, in writing and over the individual’s signature (or that of his or her representative payee, legal counsel, or other appointed representative), is in file.

2. An approved administrative discontinuation of recovery or adjustment because the overpayment is $1,000.00 or less. The $1,000 waiver tolerance applies to all requests for waiver pending or received on or after September 27, 2008. Prior to September 27, 2008 the limit was $500.00 or less.

3. An approved waiver for an overpayment caused by resources exceeding the appropriate resource limit by $50 or less.

3. Completion without field office (FO) participation

The SSA-632-BK may be completed without FO assistance.

Upon request, we provide a SSA-632-BK to the overpaid individual, his or her representative payee, legal counsel, or other appointed representative. We also inform the individual requesting a waiver that he or she may download the form from http://www.socialsecurity.gov/online/ssa-632.html

B. Description of the SSA-632-BK

1. SSA-632-BK Page 1, Identifying Information

When the form SSA-632-BK is required, page 1 is always completed. Page 1 provides identifying information and has check blocks to indicate why we are completing the form.

2. SSA-632-BK page 2, Section I, Without Fault Determination

Complete Section I only if a waiver is requested. This section collects the information needed to determine whether the liable individual was at fault in causing the overpayment. The answers must thoroughly explain the individual’s involvement in the overpayment situation. (For development of without fault see SI 02260.010.)

3. SSA-632-BK pages 3 through 7, Section II, A Financial Statement

Section II asks for a detailed description of the individual’s income and assets from all sources and the expenses of the household.

C. When not to complete the SSA-632-BK

Do not complete a SSA-632-BK if:

1. There is equivalent information, in writing and over the individual’s signature (or that of his or her representative payee, legal counsel, or other appointed representative), is in the file.

2. You approve an administrative discontinuation of recovery or adjustment because the overpayment is $1,000.00 or less.

   NOTE: Prior to September 27, 2008, the maximum amount that could be waived through the administrative discontinuation of recovery or adjustment was $500.00 or less.

   The $1,000 waiver tolerance applies to all requests for waiver pending or received on or after September 27, 2008. For a discussion on administrative discontinuation of recovery or adjustment, see SI 02260.030C.6.

   Instead of a SSA-632-BK, Document the request for waiver or reconsideration on a statement containing the following:

   • The overpaid individual’s name and account number;

   • The overpayment amount; and

   • The individuals or payee's request for waiver.

   For MSSICS cases use the DROC screen to record the required statement. For non-MSSICS cases use the NDReD process.

3. An approved waiver for an overpayment caused by resources exceeding the resource limit by $50 or less. For a discussion on waiving overpayments caused by resources exceeding the limit by $50 or less, see SI 02260.035A.1.

D. General procedures for completing the SSA-632-BK

The SSA-632-BK is designed for use with both Title II and Title XVI overpayments. Most, but not all, of the questions apply to both programs.

1. Before conducting the interview

1. Prior to the interview, review any documents that may provide useful information and/or system records relating to the overpayment (e.g., the overpayment and other notice(s), current queries (some examples are the MBR, SSID, SEQY, New Hire, HA-04, CPMS), and the folder (including, but not limited to, WMSSICS, MCS, Claims File User Interface (CFUI), Appeals Review Processing System (ARPS), NDRed).

2. Before completing the form, carefully interview the individual to be sure the SSA-632-BK is necessary and, if it is, which sections must be completed.

2. Completion without FO participation

The SSA-632-BK may be completed without FO assistance. Upon request by the overpaid individual, his or her representative payee, legal counsel, or other appointed representative, provide a SSA-632-BK.

Inform the individual(s) requesting a waiver form that he or she may download the form from http://www.socialsecurity.gov/online/ssa-632.html .

Offer assistance to the person requesting the form at the time the request is made.

You are strongly encouraged to assist in the completion of the SSA-632-BK to ensure that:

• the explanation of without fault relates to the facts surrounding the overpayment;

• the financial statements accurately reflect the person’s current situation; and

• contradictory statements are resolved.

E. Specific procedures for completing the SSA-632-BK

1. Completion of the SSA-632-BK, Page 1

a. For SSA use only

• Indicate SSI involvement; and

• List the period(s) and the amount of the overpayment.

b. Question 1

For SSI overpayments, show the SSN(s) for only the overpaid individual(s) and any representative payee.

c. Question 2

Check the appropriate block(s) to indicate what type of relief the person is seeking.

• Block A if waiver is requested.

• Block B does not pertain to SSI overpayments.

• Block C only in SSI cases, if the installment amount requested will not complete recovery within 36 months.

• Block D if an SSI recipient wants to repay the overpayment at an amount other than 10 percent of his or her total income (see SI 02220.017A.1.).

2. Completion of the SSA-632-BK, Section I - Information About Receiving the Overpayment

1. Section I is the basis for the fault determination of a waiver decision. Obtain answers that thoroughly explain why the individual believes he or she is without fault.

2. If the overpayment is caused by more than one event,obtain a separate explanation of why the individual believes he or she is without fault for each event. Do not use a separate SSA-632-BK for each event.

3. Do not complete this Section if the individual requests a lesser repayment rate or compromise settlement. Complete only Section II.

3. Completion of Section I - Individual Questions, Page 2

a. Question 3

Complete if all or part of the overpayment was received by a liable representative payee. If there was no representative payee, write in “NA”.

NOTE: For liability development see SI 02201.020 through SI 02201.023 and SI 02201.025.

b. Question 4

• Complete Question 4 only if the representative payee, spouse or sponsor is protesting his or her liability for repayment of the overpaid individual’s overpayment.

• For months prior to October 1990, if the liable spouses were not living in the same household and is without fault, stop. Recovery is against equity and good conscience (see SI 02260.025).

• Determine whether the payee requests relief from liability or assumes liability but asserts he or she is without fault.

c. Question 5

This question addresses the fault issue. It is always answered from the overpaid individual’s (including a SSI child’s) perspective. Obtain a complete statement including:

• Why the individual believed the overpaid monies were due;

• The individual’s understanding of the provisions involved in the overpayment; and,

• Why the individual believes he or she is without fault.

Have the individual explain any actions, conversations, notices, or letters that affected his or her understanding of the law and reporting responsibilities.

If the waiver request is made on behalf of a SSI child, and the child had no knowledge of the facts that caused the overpayment, record the child had no knowledge of the facts which caused the overpayment.

d. Question 6

This question gives the individual an opportunity to explain why he or she did not report any change or event.

1. If the individual alleges reporting the change or event that caused the overpayment, obtain a description of what actions he or she took to report and what, if anything, he or she did after the report.

2. If no report was made, obtain an explanation of the individual’s understanding of the reporting responsibilities in his or her own words.

3. If his or her understanding is incorrect, explain the provisions, making sure the person understands.

4. Document in the “Remarks” section (or on a Report of Contact (DROC) screen) that the individual now understands his or her reporting responsibilities. This should help to prevent additional overpayments and rebut later allegations of misinformation.

e. Question 7

This question helps you to determine whether the overpaid individual understands his or her reporting responsibilities and whether the individual has the ability to recognize recurring and related events. The answers to these questions help you in the determination of fault (see SI 02260.010A.2. and SI 02260.015B.3.).

1. Use the response to this question in conjunction with any information available about past overpayments on the master beneficiary record (MBR), supplemental security record (SSR) and the folder (including MSSICS and any other electronic documentation or evidence).

2. Do not question the individual’s veracity if our records show a prior overpayment that the individual failed to report. Instead, ask questions that may help the individual remember that a similar type of overpayment occurred and its relationship to the current overpayment. Have the individual explain why he or she believes the current overpayment is different from the prior overpayment. If the individual’s response is he or she does not remember, record that answer.

4. Completion of Section II - General

• You can help the individual complete Section II if the individual requests assistance. However, if it is more expeditious or if the individual requests it, give or mail Section II to the individual for completion and signature. You can also complete Section II in a phone interview and mail it to the individual for review and signature. If you mail Section II to the individual requesting waiver you must show the individual’s name and the SSN of the overpaid individual.

• Obtain separate financial information for the representative payee and the recipient if both are liable for an overpayment. See SI 02201.020

• If the individual requests only a determination of against equity and good conscience, financial information is not needed. For information on against equity and good conscience policy, see SI 02260.025 and GN 02250.150.

a. Credibility of answers

Accept reasonable allegations about living expenses, income, and assets. When information appears incorrect or impossible and verification is needed, see Proving Allegations on the SSA-632-BK (GN 02250.250) for guidelines.

b. A recent redetermination

Do not complete questions 14-22 if the same information was recently obtained on a SSA-8202-F6 or a SSA-8203-BK (Statement for Determining Continuing Eligibility for Supplemental Security Income), or is documented in MSSICS.

“Recently” is a RZ completed in the month the SSA-632 is filed or the prior two months.

Document the file with a photocopy of the recently completed SSA-8202-F6, SSA-8203-BK, signed MSSICS redetermination form, or printed copies of the applicable MSSICS screens.

c. When not to complete Section II

Do not complete Section II if:

• the overpaid individual is currently eligible to receive SSI payments; and

• the overpaid individual’s current total countable income does not exceed the:

• Federal benefit rate (FBR); plus

• $20 general income exclusion; plus

• $65 earned income exclusion; plus

• Applicable federally-administered State supplement (see SI 02260.020); or

• Individual receives cash public assistance which can be verified.

• If these conditions are met complete only questions 8, 9 (if 8B is answered “yes”), 10, 11, and 12. Go to page 8.

EXCEPTION: If the recipient requests a repayment amount that is below the 10% rate of recovery the CR may complete Section II to evaluate the recipient’s ordinary and necessary living expenses.

d. When to complete Section II

If the individual receiving SSI has countable earned income of more than $65, or is in non-payment, then complete all questions in Section II.

5. Completion of Section II – Individual Questions

a. Questions 8, 9 and 10 - Possession of the Overpayment

Questions 8, 9 and 10 help you to determine whether recovery from the amount of the overpayment in the person’s possession would defeat the purpose of Title XVI (see SI 02260.020A.3. and SI 02260.020B.5.).

Remember: You can not find that recovery would defeat the purpose of Title XVI if the overpaid individual has possession of the incorrect payments (or proceeds from payments in identifiable liquid resources) which accumulated during the overpayment period.

b. Transfer of resources

To determine eligibility for SSI, you must determine the value of an individual's resources at the first moment of the month. Transferring ownership of a resource may affect the value of an individual's countable resources, which in turn can affect SSI eligibility.

Transferring ownership of a resource for less than its fair market value can result in a period of ineligibility for SSI. Therefore, if an individual alleges that a resource has been transferred, develop this issue.

We must notify State Medicaid agencies of resource transfers, regardless of when the transfer occurred. See SI 01150.000 (Other Resource Provisions)

c. Question 13 Members of Household

This question allows the individual to describe his or her household composition and the relationship of the dependent people in the household.

In general, an individual receiving SSI at the time the form is completed does not have to answer any more questions. However, if the individual also receives countable earned income of more than $65, or is in non-payment, complete all questions in Section II.

d. Questions 14 through 18 Income and Assets - General

Total monthly income

The answers to questions 14 through 18 are used to determine the total monthly income and assets available to the individual who requests waiver of recovery.

Use the current month’s income.

The total monthly income includes the total amount of income available to both the individual and other household members including income that is deemable to the individual from a parent, spouse, sponsor, or an essential person.

If there is self-employment income, show one-twelfth of the anticipated net earnings for the year.

Total assets

Questions 14 and 15 include all net resources deemable to the overpaid recipient from a parent, spouse, sponsor, or essential person. Net resources are those remaining after deducting the applicable allowable exclusions.

e. Question 14

Part A - Do not include the proceeds of any monthly income listed in Questions 17 ad 18, such as a cashed a paycheck. Do not count the same money in both question 14 and question 18.

Part B - If the answers indicate that the individual is receiving income from his or her assets, include that income on line K of Question 18.

f. Question 15

Part A - List, but do not count as an asset, the principal vehicle used for family or work transportation.

Part B - Do not include the primary residence.

g. Questions 16, 17 and 18

Include the individual’s income from all sources. Include the income of a spouse, or parent(s) if applicable. Clearly show to whom the income belongs.

Total each column to show household income. To convert all income to monthly totals:

• Multiply weekly income by 13;

• Divide by 3;

• Divide quarterly income by 3;

• Divide yearly income by 12.

• Show deemed income in question 18.L.

The shaded areas after each column apply to title II.

h. Question 19

Show “cc” in the expense line if the expense (e.g., clothing) is also listed in line F (credit card payments). Do not double count expenses.

Show average monthly household expenses in the amount column. Household expenses are for all household members, not just the overpaid person, his or her spouse or parent(s). To convert all expenses to monthly totals:

• Multiply weekly expenses by 13;

• Divide by 3;

• Divide quarterly expenses by 3;

• Divide yearly expenses by 12.

• Include in “Expense Remarks” any expenses unique to only one household member as well as any unusual or very large expenses.

The shaded column on the right applies to title II.

i. Question 20

Part C applies to title II.

Insert the amount in Part B into Part D.

j. Question 21

The explanation helps to determine whether the person has any income or resources not shown on previous questions or if he or she is going into debt each month.

“For SSA Use Only”

When item 20A exceeds item 20D, enter difference in the top block.

When item 20D exceeds item 20A, enter difference in the lower block.

k. Question 22

Part A The answer helps to determine whether you should look beyond the immediate comparison of income and expenses from Question 20.

Part B The answer reveals if the “ready cash” amount (if any) shown in question 14A can be used in the determination of the ability to repay.

Parts C and D The answers to parts C and D help to determine whether the listed assets (if any) can be converted to cash for the individual to use to repay the overpayment(s) and if not, why not.

NOTE: Neither the vehicle used for transportation or the property where the overpaid individual lives are countable assets.