SSA-2032-BK Request for Waiver of Special Veterans Benefits (SVB) Ov

Form SSA-2032-BK (XX-XXXX)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0698

Request for Waiver of Special Veterans Benefits (SVB)
Overpayment Recovery or Change in Repayment Rate
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.

FOR SSA USE ONLY
Input Date
Waiver Approval
Denial

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.
If you need more room for responses, use “REMARKS” on
page 9.

1. Name of Beneficiary

Name of Representative Payee (if applicable)

Amt of O/P (Show in U.S. $)

Period (Dates) of O/P
MM/YYYY to MM/YYYY

Social Security Number

Social Security Number

If representative payee is requesting waiver or change in repayment rate, answer 1.A. and 1.B.
and continue:
A. Were all or some of the overpaid SVB payments received used for the beneficiary?
If yes, answer B. below.
Yes
If no, skip to Question 2.
No
Address of the beneficiary

B. How were the overpaid benefits used?

2. If you are requesting waiver of the overpayment, please check block A. if it applies to you:
A. The SVB overpayment was not my fault and I cannot afford to pay the money back and/or it is
unfair to make me pay the money back for some other reason. (Explain in “REMARKS” on
page 9.)
If you are currently receiving SVB, please check block B. if it applies to you:
B. I am receiving SVB, but cannot afford to have the amount of my monthly benefit (or an amount
equal to 10% of the maximum SVB monthly payment amount, whichever is less) withheld from
my SVB to pay back the overpaid benefits I received. Instead, I want $
(cannot
be less than $1) withheld each month from my SVB to pay back the overpayment.
If you are no longer receiving SVB, check block C. if it applies to you:
(cannot be less than $10) each month instead of repaying
C. I want to pay back $
the SVB overpayment at once.

Form SSA-2032-BK (XX-XXXX)

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SECTION 1 - INFORMATION ABOUT RECEIVING THE OVERPAYMENT
3. Why did you think you were due the overpaid money and why do you think you were not at fault in
causing the overpayment or accepting the money?

4. A. Did you tell us about the change or event that made you overpaid?
Yes If yes, complete 4.B. and, if applicable, 4.C. below.
No If no, why didn’t you tell us?
B. If yes, how, when and where did you tell us? If you told us by phone or in person, with whom did you
talk, and what was said?

C. If you did not hear from us after your report, and/or the amount or payment of your SVB did not
change, did you contact us again?
Yes If yes, what were you told would happen?

No
5. A. Have we ever overpaid you before?
Yes
No

If yes, complete B. and C. below
If no, skip to Question 6.

B. If yes, on what Social Security number were you overpaid?

C. Why were you overpaid before? If the reason is similar to why you are overpaid now, explain what you
did to try to prevent the present overpayment.

SECTION 2 - YOUR FINANCIAL STATEMENT
You must complete this section if you are asking us either to waive the collection of the overpayment or to
change the rate at which we asked you to repay it. Please answer all questions as fully and as carefully as
possible. We may ask to see some documents to support your statements, so you should have them with
you when you visit our office, or we may ask you to send them to us.
Examples of documents are:
• Current rent or mortgage books
• Savings passbooks
• Pay stubs
• Your most recent tax return
• 2 or 3 recent utility, medical, charge card and insurance bills
• Cancelled checks
• Similar documents for your spouse or dependent family members
You can express amounts in local currency. If U.S. currency is shown, show whole dollar amounts only –
round any cents to the nearest dollar.

Form SSA-2032-BK (XX-XXXX)

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6. A. Do you now have any of the overpaid benefits in your possession (or in a savings or other type
of account)?
Yes Amount:
Please contact SSA personnel as shown in “IMPORTANT”
below to return these funds to SSA.
No
B. Did you have any of the overpaid benefits in your possession (or in a savings or other type of account)
when you received the overpayment notice?
Yes

Amount:

Please complete Question 7 below.

No
7. Explain why you believe you should not have to return this amount.

8. A. Are you now receiving U.S. Federal, state or local cash public assistance such as Supplemental
Security Income (SSI) payments?
Yes If yes, answer B. and C. See “IMPORTANT” below.
No
B. Name or kind of public assistance

C. Claim number
IMPORTANT: If you answered “Yes” to Question 8, DO NOT answer any more questions on this form. Go
to page 10 at the end of the form and provide the date and your contact information. Bring or mail this form
(and any papers that show you receive U.S. Federal, state or local public assistance, if this is the case) to
your local Social Security office or to the U.S. Embassy, SSA, 1201 Roxas Blvd., Ermita 0930 Manila as
soon as possible.
MEMBERS OF HOUSEHOLD – DO NOT Complete if Answer to 8.A. was “Yes”
9. List any person (child, parent, friend, etc.) who depends on you for support and who lives with you.
Name

Age

Relationship
(If none, say why the person is your dependent)

Form SSA-2032-BK (XX-XXXX)

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ASSETS - THINGS YOU HAVE AND OWN –
DO NOT Complete if Answer to 8.A. was “Yes”
10. A. How much money do you and any person(s) listed in Question 9 above have as cash on hand, in a
checking account, or otherwise readily available?
Amount:
B. If there is an amount of cash on hand or in checking accounts shown in Question 10.A., is it being
held for a special purpose?
No amount on hand
No (Money available for any use.)
Yes (Explain on line below.)

C. Does your name, or that of any other member of your household, appear either alone or with any
other person, on any of the following?

Type of Asset

Owner

Balance or Value

Show the Income
(interest, dividends)
Earned Each Month.
(If none, explain in
spaces below.) If paid
quarterly, divide by 3.

Savings (Bank,
Savings and Loan,
Credit Union)
Certificates of
Deposit (CD)
Individual Retirement
Account (IRA)
Money or
Mutual Funds
Bonds, Stocks
Trust Fund
Checking Account
Other (Explain)

Totals
D. Is there any reason you CANNOT convert to cash the “Balance or Value” of any financial asset
shown in Question 10.C.?
Yes If yes, explain on line below.

No

Form SSA-2032-BK (XX-XXXX)

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11. A. If you or a member of your household owns a car, van, truck, camper, motorcycle or any other
vehicle or a boat, (other than a vehicle used for family or work transportation) list below.
Year,
Make/Model

Owner

Present Value

Loan Balance
(if any)

Main Purpose for
Use

B. If you or a member of your household owns any real estate (buildings or land), OTHER than where
you live; or owns or has an interest in any business, property or valuables, describe below.
Owner

Description

Market Value

Loan Balance
(if any)

Usage-Income
(rent, etc.)

C. Is there any reason you CANNOT SELL or otherwise convert to cash any of the assets shown in
Question 11.A. and 11.B.?
Yes If yes, explain on line below.

No
MONTHLY HOUSEHOLD INCOME
BE SURE TO SHOW MONTHLY AMOUNTS BELOW. If paid weekly, multiply by 4.33 (4 1/3) to figure
monthly pay. If paid every 2 weeks, multiply by 2.166 (2 1/6). If self-employed, enter 1/12 of net earnings.
Also, enter monthly TAKE HOME amounts on line A of Question 14.
12. A. Are you employed?
Yes If yes, provide information below.
No If no, skip to 12.B.
Employer Name
Employer Address
Employer Telephone Number
If self-employed write “Self”
Monthly pay before any deduction: (Gross)
Monthly TAKE HOME pay (Net)

Form SSA-2032-BK (XX-XXXX)

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12. B. Is your spouse employed?
Yes If yes, provide information below.
No

If no, skip to 12.C.

Employer Name
Employer Address
Employer Telephone Number
If self-employed write “Self”
Monthly pay before any deduction: (Gross)
Monthly TAKE HOME pay (Net)
C. Is any other person listed in Question 9 above employed?
Yes
No
Name(s) of Person listed in Question 9
Employer Name
Employer Address
Employer Telephone Number
If self-employed write “Self”
Monthly pay before any deduction: (Gross)
Monthly TAKE HOME pay (Net)
13. A. Do you, your spouse or any dependent member of your household receive support or contributions
from any person or organization?
Yes If yes, answer 13.B.
No If no, skip to Question 14.
B. How much money is received each month?
Amount $
(Show this amount on line K of Question 14.)
Source of support or contributions

Form SSA-2032-BK (XX-XXXX)

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MONTHLY INCOME
14. BE SURE TO SHOW MONTHLY AMOUNTS BELOW. If paid weekly, multiply by 4.33 (4 1/3) to figure
monthly pay. If paid every 2 weeks, multiply by 2.166 (2 1/6).
INCOME FROM #12 & #13 ABOVE,
AND OTHER INCOME TO YOUR
HOUSEHOLD

YOURS

SPOUSE'S

A. TAKE HOME Pay (Net) (From
#12 A, B, and C above)
B. SVB
C. SOCIAL SECURITY
RETIREMENT & SURVIVORS
BENEFITS (e.g., spouse/widow
[er] benefits)
D. SUPPLEMENTAL SECURITY
INCOME (SSI)
E. TYPE OF PENSIONS (VA,
PVAO, PSSS, Military, Civil
Service, Railroad, etc.)
F. TYPE OF PUBLIC ASSISTANCE
(Other than SSI)
G. FOOD STAMPS (Show full face
value of stamps received)
H. INCOME FROM REAL ESTATE
(rent, etc.) (From #11B above)
I. ROOM AND/OR BOARD
PAYMENTS (Explain in Remarks,
below)
J. CHILD SUPPORT AND/OR
ALIMONY
K. OTHER SUPPORT (From #13B
above)
L. INCOME FROM ASSETS (From
#10 above)
M. OTHER (From any source,
explain below)
TOTALS

GRAND TOTAL: (Add total of 3 blocks from Question 14.)
REMARKS

OTHER
HOUSEHOLD
MEMBERS

SSA USE ONLY

Form SSA-2032-BK (XX-XXXX)

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MONTHLY HOUSEHOLD EXPENSES
15. BE SURE TO SHOW MONTHLY EXPENSES BELOW. If paid weekly, multiply by 4.33 (4 1/3) to figure
monthly pay. If paid every 2 weeks, multiply by 2.166 (2 1/6).
DO NOT list an expense that is withheld from income (such as Medical Insurance under Medicare).
Only take home pay is used to figure income.
Show “CC” as the expense amount if the expense (such as clothing) is part of CREDIT CARD
EXPENSE shown on line 15.F.
Amount per month

MONTHLY HOUSEHOLD EXPENSES

SSA USE ONLY

A. Rent or Mortgage (If mortgage payment includes property or other local taxes,
insurance, etc. DO NOT list again below.)
B. Food (groceries—include the value of food stamps) and food at restaurants,
work, etc.
C. Utilities (gas, electricity, telephone)
D. Other heating/cooking fuel (oil, propane, coal, wood, etc.)
E. Clothing
F. Credit card payments (Show minimum monthly payment allowed.)
G. Property tax
H. Other taxes or fees related to your home (trash collection, water-sewer fees)
I. Insurance (life, health, fire, homeowner, renter, car, and any other casualty or
liability policies)
J. Medical-Dental (after amount, if any, paid by insurance)
K. Car operation and maintenance (Show any car loan payment in N below.)
L. Other transportation
M. Church-charity cash donations
N. Loan, credit, lay-away payments (If payment amount is optional, show
minimum.)
O. Support to someone NOT in household (Show name, age, relationship (if any)
and address.)
P. Any expense not shown above (Specify)
Total

EXPENSE REMARKS: (Also explain any unusual or very large expenses, such as medical, college, etc.)

Form SSA-2032-BK (XX-XXXX)

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INCOME AND EXPENSES COMPARISON
Amount
16. A. Monthly Income (Write the amount from the Grand Total of Question #14.)
B. Monthly Expenses (Add $10 to the amount from the Total of Question #15.)
17. If your expenses shown in 16.B. are more than your income shown in 16.A., explain how you are paying your bills
in the space below.

FOR SSA USE ONLY
Income =

+

INCOME LESS THAN MONTHLY EXPENSES Income =

–

INCOME EXCEEDS MONTHLY EXPENSES

FINANCIAL EXPECTATION AND FUNDS AVAILABILITY
18. Do you, your spouse or any dependent member of your household expect your or their financial
situation to change (for the better or worse) in the next 6 months? (For example: Expect tax refund, pay
raise or full repayment of a current bill for the better; or major house repairs expected for the worse.)
Yes If yes, explain on line below.

No
REMARKS SPACE: If you are continuing an answer to a question, please show the number and letter (if
any) of the question you are responding to.

Form SSA-2032-BK (XX-XXXX)

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IMPORTANT: Anyone who knowingly makes or causes to be made a false statement or representation of
material fact for use in determining a payment under the Social Security Act, or knowingly conceals or fails
to disclose an event with an intent to affect an initial or continued right to payment, or submits or causes to
be submitted any false statement or document knowing the same to contain any misrepresentation of
material fact, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be
subject to administrative sanctions.
CONTACT INFORMATION OF OVERPAID PERSON OR REPRESENTATIVE PAYEE
Name (First name, middle initial, last name in ink)

Home Telephone Number (Include area code)

Date (MM/DD/YY)

Work Telephone Number if we may call you at Work
(Include area code)

Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)

City

Zip Code

State

Country

Enter Name of County (if any) in Which You Now Live

Form SSA-2032-BK (XX-XXXX)

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Privacy Act Statement
Collection and Use of Personal Information
Sections 808 and 1147 of the Social Security Act, as amended, allow us to collect this information.
Furnishing this information is voluntary. However, failing to provide all or part of the information may affect
your benefits.
We will use the information to make a determination on your overpayment waiver request or change your
monthly repayment rate. We may also share your information for the following purposes, called routine
uses:
• To representative payees, when the information pertains to individuals for whom they serve as
representative payees, for the purpose of assisting the Social Security Administration (SSA) in
administering its representative payment responsibilities under the Act and assisting the
representative payees in performing their duties as payees, including receiving and accounting
for benefits for individuals for whom they serve as payees; and
• To third party contacts (including private collection agencies under contract with SSA) for the
purpose of their assisting SSA in recovering overpayments.
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 (SORN)
60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits, as published in
the Federal Register (FR) on January 11, 2006, at 71 FR 1830, and 60-0273, entitled Social Security Title
VIII Special Veterans Benefits Claims Development and Management Information System, as published
in the FR on March 14, 2000, at 65 FR 13803. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy.
PAPERWORK REDUCTION ACT STATEMENT
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid
Office of Management and Budget (OMB) control number. We estimate that it will take about 120 minutes
to read the instructions, gather the facts, and answer the questions. Send only comments relating to
our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.