Form SSA-2032-BK Request for Waiver of special veterans Benefit (SVB) Ove

Form SSA-2032 (05-2016)
Discontinue Previous 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

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

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

Social Security Number

Name of Representative Payee (if applicable)

-

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
No

If no, skip to Question 2.

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:
C. I want to pay back $
(cannot be less than $10) each month instead of repaying
the SVB overpayment at once.

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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
No

If yes, complete 4.B. and, if applicable, 4.C. below.
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?
If yes, what were you told would happen?
Yes

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.

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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
No

If yes, answer B. and C. See “IMPORTANT” below.

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 the spaces provided on page 10 at the end of the form for signature and date. Sign and date the form,
and provide your address and a telephone number. 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 (05-2016)

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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

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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 Main Purpose
(if any)
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 Usage-Income
(if any)
(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)

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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

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MONTHLY 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).
14. INCOME FROM #12 & #13 ABOVE,
AND OTHER INCOME TO YOUR
HOUSEHOLD

YOURS

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

SPOUSE'S

OTHER
HOUSEHOLD
MEMBERS

SSA USE ONLY

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MONTHLY HOUSEHOLD EXPENSES
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

15. 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.)

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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 EXCEEDS MONTHLY EXPENSES

Income=

+

INCOME LESS THAN MONTHLY EXPENSES

Income=

–

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.

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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
PRINT (First name, middle
initial, last name in ink)

DATE
(MM/DD/YY)

HOME TELEPHONE NUMBER
(Include area code)

WORK TELEPHONE NUMBER
IF WE MAY CALL YOU AT
WORK (Include area code)

SIGNATURE
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

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.
SIGNATURE OF WITNESS
ADDRESS (Number and street,
City, State and Zip Code, Country)
SIGNATURE OF WITNESS
ADDRESS (Number and street,
City, State and Zip Code, Country)

Form SSA-2032 (05-2016)

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Privacy Act
Collection and Use of Personal Information
42 U.S.C 404, 1008,1383(b), 1399gg, the Social Security Protection Act of 2004 (P.L.108-203) and the Federal Coal Mine
Health and Safety Act of 1969, authorize us to collect this information. We will use the information you provide on this form to
decide if we can waive collection of the overpayment or change the amount you must pay us back each month.
Completion of this form is voluntary; however, failure to provide all or part of the requested information could prevent us from
waiving collection of the overpayment or change the amount you must repay us each month. Failure to report all events, which
can cause suspension of benefits, may also cause the loss of additional benefits.
We rarely use the information you supply for any purpose other than for determining continuing eligibility. However, we may
use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits
and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government
Accountability Office and Department of Veterans' affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and
local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of
Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare our records with
records kept by other Federal, State or local government agencies. Information from these matching programs can be used to
establish or verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of payments
or delinquent debts under these programs.
Complete lists of routine uses for this information are available in our Systems of Records Notices entitled, the Master
Beneficiary Record (60-0090) and the Recovery of Overpayments, Accounting and Reporting/Debt Management System
(60-0094). These notices, additional information regarding this form, routine uses of information, and our programs and
systems are available on-line at www.socialsecurity.gov or at your local Social Security office.

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 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 on our time estimate above to SSA, 6401
Security Blvd., Baltimore, MD 21235-6401.