SSA-634 Request for Change in Repayment Notice

Form SSA-634 (XX-2017)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0037

Request for Change in Overpayment Recovery Rate
When To Complete This Form
Complete this form if you are requesting that we adjust the current rate of withholding to recover your
overpayment because you are unable to meet your necessary living expenses. We will use your answers to
decide if we can reduce the amount you must pay us back each month.
IMPORTANT: Please answer the following questions as completely as you can. If you are answering the
questions for someone else, check the boxes and answer each question as it applies to the overpaid person.

SECTION 1 - IDENTIFYING QUESTIONS
1.

A. What is the name, Social Security Number, and claim number (if any) of the overpaid person?
Name:
SSN:

Claim Number:

B. Are you the overpaid person?

Yes (go to question 2)

No (go to question 1.C)

C. If you are not the overpaid person, what is your relationship to the overpaid person?
(Check all that apply)
I am the overpaid person's parent.
I am the overpaid person's spouse.
Other, please explain:

I am the overpaid person's representative payee.
I am the overpaid person's legal guardian.

D. If you are not the overpaid person, what is your name or the name of the organization you
represent?
Name:
2.

Please check all that apply:
I am receiving Supplemental Security Income (SSI) benefits.
I am receiving Temporary Assistance for Needy Families (TANF)
I am receiving a pension based on need from the Department of Veterans Affairs (VA)
I am receiving Social Security benefits.
I am not receiving benefits.

3.

Enter the total amount you owe: $

4.

Enter the amount you can afford to pay or have
withheld from your payment each month: $

Form SSA-634 (XX-2017)

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YOUR FINANCIAL STATEMENT
Documents to Support Your Statements
Please answer all questions and submit any supporting documents with your request. Your supporting
documents should be no older than 3 months from the date you are requesting a change in the repayment
rate.
Examples of supporting documents are:
• Current Rent or Mortgage Information
• Recent Bank Statements (checking or savings
• 2 or 3 Recent Utility, Medical, Charge Card, and
account)
Insurance Bills
• Current Pay Stubs
• Canceled Checks
• Your Most Recent Income Tax Return
Please write only whole dollar amounts. Round any cents to the nearest dollar. If you need more space for
answers, use the "Remarks" section at the bottom of page 6.

SECTION 2 - ASSETS - THINGS YOU HAVE AND OWN
5.

A. How much cash do you have in your possession? $
B. List all of your financial accounts. Examples of accounts you should list include: Checking, Online
(e.g., PayPal), Savings, Certificate of Deposit (CD), Individual Retirement Accounts (IRAs), Money
or Mutual Funds, Stocks, Bonds, Trust Funds, Prepaid Debit Cards, or any other accounts.
Type of
Account

Name and Address
of Institution

Name on
Account

Balance or Value

Income Per
Month (interest
or dividends)

Account Number

TOTALS $

6.

A. Do you own more than one family vehicle, including a car, sport utility vehicle (SUV), truck, van,
camper, motorcycle, boat, or any other vehicle?
Yes (list all the vehicles below)
No (go to 6.B)
Owner

Year, Make/Model

Present Value

Loan Balance
(if any)

Main Purpose for Use

TOTAL COUNTABLE VALUE $ 0.00

(Options continue on next page)

Form SSA-634 (XX-2017)

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6. B. Do you own any real estate other than where you live?
Yes (list below)
No (go to 6.C)
Owner

Description

Market Value

Loan Balance
(if any)

Income Amount

0.00

TOTALS $

C. Do you own or have an interest in any business, property, or valuables?
Yes (list below)
No (go to 7)
Owner

Description

Market Value

Loan Balance
(if any)

Income Amount

0.00

TOTALS $

SECTION 3 - MONTHLY HOUSEHOLD INCOME
The next question asks about monthly take home pay. Enter your take home pay, and check the box to
show whether you are paid weekly, every 2 weeks, twice a month, or monthly. Add the monthly amount on
line 9.A.
7. Are you employed?

Yes (provide information below)

Employer Name, Address, and Phone: (Write "self" if self-employed)

No
Take home pay or earnings if $
self-employed (Net) Choose one:
Weekly

Every 2 Weeks

Monthly

Twice a Month

8. A. Do you receive support or contributions from any person or organization?
Yes (go to question 8.B)
No (go to question 9)
B. Is the support received under a loan agreement?
No (go to question 8.C)

Yes (go to question 9)

C. How much money do you receive each month? (Show this amount on line I of question 9)
$
9.

Source

Income (Be sure to show monthly amounts below)

Your Income

SSA USE
ONLY

A. Take Home Pay (Net) (from question 7)
B. Social Security Benefits (retirement, disability, widows,
students, etc.)
C. Supplemental Security Income (SSI)
(Options continue on next page)

Form SSA-634 (XX-2017)

9.

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TYPE
D. Pension(s) (VA, Military,
Civil Service, Railroad, etc.) TYPE
E. Supplemental Nutrition Assistance Program (SNAP) Benefits
F. Income from Real Estate, Business, etc.
(from question 6.B and 6.C)
G. Room and/or Board Payments from a person who is not a
Dependent. Explain in Remarks below.
H. Child Support/Alimony
I. Other Support (from question 8.C)
J. Income from Assets (from question 5.B)
K. Other (from any source, explain in REMARKS below)
TOTAL:

REMARKS:

SECTION 4 - MONTHLY HOUSEHOLD EXPENSES
DO NOT list an expense that is withheld from your paycheck (such as medical insurance, child support,
alimony, wage garnishments, etc.). (Be sure to show monthly average amounts in number 10).
Please write only whole dollar amount and round any cents to the nearest dollar.
10.
SSA USE
Type of Expense
$ Per Month
ONLY
A. Rent or Mortgage (if mortgage payment includes property or other
local taxes, insurance, etc., DO NOT list again below)
B. Food (groceries, including food purchased with SNAP benefits,
and food at restaurants, work, etc.)
C. Utilities (Gas, electric, telephone (cell or land line), Internet, trash
collection, water, and sewer)
D. Other Heating/Cooking Fuel (oil, propane, coal, wood, etc.)
E. Clothing
F. Household Items (personal hygiene items, etc.)
G. Property Tax (State and local)
H. Insurance (life, health, fire, homeowner, renter, car, and any other
casualty or liability policies)
(Options continue on next page)

Form SSA-634 (XX-2017)

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10. I. Medical/Dental (prescriptions and medical equipment, if not paid
by insurance)
J. Vehicle Loan/Lease Payment
K. Vehicle Expenses (gas and repairs)
L. Other Transportation (bus, taxi, etc., used for medical
appointments, work, or other necessary travel)
M. Tuition and School Expenses
N. Court Ordered Payments Paid Directly to the Court
O. Credit Card Payments (show minimum monthly payment).
DO NOT include any expenses already listed above
P. Any expense not shown above

TOTAL
EXPENSE REMARKS: (Please provide any additional information not included above. Also, explain
any unusual or very large expenses such as medical, college, etc.)

SECTION 5 - INCOME AND EXPENSES COMPARISON
11. A. Your Monthly Income
Write the amount here from "Total" of question 9.

$

B. Your Monthly Expenses
Write the amount here from "Total" of question 10.

$

C. Total
Subtract B from A.

$

12. If your expenses in 11.B are more than your income in 11.A, explain how you are paying your bills.
If you are not paying your bills, explain which bills have unpaid balances.

Form SSA-634 (XX-2017)

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SECTION 6 - FINANCIAL EXPECTATION AND FUNDS AVAILABILITY
13. A. Do you expect to receive an inheritance within the next 6 months?
Yes (Explain on line below)
No (go to 13.B)

B. Is there any reason you cannot convert or sell the “Balance or Value” of any financial assets
shown in items 5.B, 6.A, 6.B, or 6.C to cash?
Yes (Explain on line below)

No

C. Please provide the total of your assets from questions, 5.A, 5.B, 6.A, 6.B, and 6.C
Total $:

REMARKS SPACE - If you are continuing an answer to a question, please write the number
(and letter, if any) of the question first.

Form SSA-634 (XX-2017)

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PENALTY CLAUSE, CERTIFICATION, AND PRIVACY ACT STATEMENT
I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that
anyone who knowingly gives a false statement about a material fact in this information, or causes someone
else to do so, commits a crime and may be subject to a fine or imprisonment.
SIGNATURE OF OVERPAID PERSON OR REPRESENTATIVE PAYEE
Signature (First name, middle initial, last name) (Write in ink)

Home Telephone Number (include area code)

Date (MM/DD/YYYY)

Work Telephone Number If We May Call You At
Work (include area code)

Mailing Address (Number and street, Apt. No., PO Box, or Rural Route

City

State

ZIP Code

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by
mark (X), two witnesses to the signing who know the individual must sign below, giving their full
addresses.
1. Signature of Witness (Write in ink)

2. Signature of Witness (Write in ink)

Address (Number and street, City, State, and ZIP Code) Address (Number and street, City, State, and ZIP Code)

Form SSA-634 (XX-2017)

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About the Privacy Act
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 request for change in overpayment recovery rate.
We will use the information to make a determination regarding overpayment recovery. We may also share
your information for the following purposes, called routine uses:
1. To employers to assist the Social Security Administration (SSA) in the collection of debts owed by
former beneficiaries and representative payees of Social Security payments who received an
overpayment and owe a delinquent debt to the SSA; and
2. To another Federal agency that has asked SSA to effect an administrative offset under common
law or under 31 U.S.C. 3716 to help collect a debt owed the United States.
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 (SORNs) 60-0094,
entitled Recovery of Overpayments, Accounting and Reporting/Debt Management System; 60-0231, entitled
Financial Transactions of SSA Accounting and Finance Offices; and 60-0320, entitled Electronic Disability
Claims File. Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.

Paperwork Reduction Act Statement - 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. We estimate that it
will take about 2 hours to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is 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.