Form SSA-640 Financial Disclosure for Civil Monetary Penalty (CMP) De

Form SSA-640 (11-2018)
Discontinue Prior Editions
Social Security Administration

Page 1 of 9
OMB No. 0960-0776

Financial Disclosure for Civil Monetary Penalty (CMP) Debt
FOR SSA USE ONLY
We will use this form to obtain financial information relating to the recovery of your
CMP debt.
Please print your answers to 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.

Input Date:
Amount of CMP $
Violation:
Title II

Title XVI

ACTION:
Approved $
Denied

A. Name of person who owes the Civil Monetary Penalty (CMP)

B. Social Security Number

YOUR FINANCIAL STATEMENT
Please answer all the questions as fully and completely 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.
EXAMPLES ARE:
• Current Rent or Mortgage Statements

• 2 or 3 recent utility, medical, charge card, and
insurance bills

• Savings Account Statements

• Checking Account Statements

• Papers showing you are receiving public
assistance

• Similar documents for your spouse or dependent
family members

• Your most recent Tax return

• Pay stubs

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.
1. A. Did you lend or give away any property or cash after
Yes
No
notification of the CMP?
(Answer Part B)
(Go to question 2)
B. Who received it, relationship (if any), description and value:

2. A. Did you receive or sell any property or receive any cash
(other than earnings) after notification of this CMP?
B. Describe property and sale price or amount of cash received:

3.

A. Are you now receiving cash public assistance?
B. Name or kind of public assistance

Yes
(Answer Part B)

Yes
(Answer Part B and C)
C. Claim Number

No
(Go to question 3)

No
(Go to question 4)

Form SSA-640 (11-2018)

Page 2 of 9

MEMBERS OF HOUSEHOLD
4. List any person (child, parent, friend, etc.) who depends on you for support AND who lives with you.
NAME

AGE

RELATIONSHIP (if none, explain why the person is
dependent on you)

ASSETS - THINGS YOU HAVE AND OWN
5. A. How much money do you and any person(s) listed in question 4 above have as cash on hand, in a
$
checking account, or otherwise readily available?
B. 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

SAVINGS (Bank, Savings
and Loan, Credit Union)
CERTIFICATES OF
DEPOSIT (CD)
INDIVIDUAL RETIREMENT
ACCOUNT (IRA)
MONEY OR MUTUAL
FUNDS

SHOW THE INCOME (interest, dividends)
BALANCE OR
PER MONTH EARNED EACH MONTH. (If none, explain in
VALUE
spaces below. If paid quarterly, divide by 3).
$

$

$

$

$

$

$

$

BONDS, STOCKS

$

$

TRUST FUND

$

$

CHECKING ACCOUNT

$

$

ABLE ACCOUNT

$

$

$

$

OTHER (EXPLAIN)

TOTALS $

0.00

$

0.00

Enter the "Per Month" total on line (k) of
question 9.

6. A. If you or a member of your household own a car, (other than the family vehicle), van, truck, camper, motorcycle, or any
other vehicle or a boat, list below.
OWNER

YEAR, MAKE/
MODEL

LOAN
BALANCE
(if any)

PRESENT
VALUE
$

$

$

$

$

$

MAIN PURPOSE FOR USE

Form SSA-640 (11-2018)

Page 3 of 9

6. B. If you or a member of your household own any real estate (buildings or land), OTHER than where you live, or own or have
an interest in, any business, property, or valuables, describe below.
OWNER

LOAN
BALANCE
(if any)

MARKET
VALUE

DESCRIPTION
$

$

$

$

$

$

USAGE INCOME (rent, etc.)

MONTHLY HOUSEHOLD INCOME
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 selfemployed, enter 1/12 of net earnings. Enter monthly TAKE HOME amounts on line A of question 9 also.
7.

Yes
No
(Provide information below)
(Skip to B)
Employer's name, address and phone: (Write "self" if self-employed.)
Monthly pay before
deduction (Gross) $

A. Are you employed?

Monthly TAKE
HOME pay (NET)

$

Yes
No
(Provide information below)
(Skip to C)
Employer's name, address and phone: (Write "self" if self-employed.)
Monthly pay before
deduction (Gross) $

B. Is your spouse employed?

Monthly TAKE
HOME pay (NET)

$

C. Is any other person listed in Question 4 employed?
No
(Go to question 8)

Yes Names:
Employer's name, address and phone: (Write "self" if self-employed.)

Monthly pay before
deduction (Gross) $
Monthly TAKE
HOME pay (NET)

8. A. Do you, your spouse or any dependent member of your
household receive support or contributions from any
person or organization?
B. How much money is received each month?
(Show this amount on line (J) of question 9)

Yes
(Answer B)
Source
$

$

No
(Go to question 9)

Form SSA-640 (11-2018)

Page 4 of 9

SPOUSES

DEPENDENT
HOUSEHOLD
MEMBERS

A. TAKE HOME Pay (NET) (From #7, A, B,
C above)

$

$

$

B. Social Security Benefits

$

$

$

C. Supplemental Security Income (SSI)

$

$

$

D. Pension(s) (specify type) (VA, Military, Civil
$
Service, Railroad, etc.)

$

$

E. Public Assistance

$

$

$

$

$

$

$

$

$

$

$

$

I. Child Support/Alimony

$

$

$

J. Other Support (From #8(B) above)

$

$

$

K. Income From Assets (From question 5)

$

$

$

L. Other (From any source, explain below)

$

$

$

F. Food Stamps (Show full face value of
stamps received)
G. Income from real estate (rent, etc.)
(From question 6B)
H. Room and/or Board Payments (Explain in
remarks below)

TOTALS $

0.00

$

0.00

$

CHECK

YOURS

CHECK

INCOME FROM #7 AND #8 ABOVE AND
OTHER INCOME TO YOUR HOUSEHOLD

CHECK

9. BE SURE TO SHOW MONTHLY AMOUNTS BELOW - If received weekly or every 2 weeks, read the instruction directly
above #7

0.00

GRAND TOTAL
$
(add 3 total blocks above)
Remarks

SSA USE ONLY

0.00

Form SSA-640 (11-2018)

Page 5 of 9

MONTHLY HOUSEHOLD EXPENSES
If the expense is paid weekly or every 2 weeks, read the instruction on Page 3. Do NOT list an expense that is withheld from
income (Such as Medical Insurance). 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 (F).
10.
$ PER
CC SSA USE ONLY
MONTH
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, electric, 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 (State and local)

$

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. Total Church-Charitable Contributions

$

N. Loan, credit, lay-away payments (If payment amount if optional, show minimum)

$

N. Loan, credit, lay-away payments (If payment amount if optional, show minimum)
(cont.)
N. Loan, credit, lay-away payments (If payment amount if optional, show minimum)
(cont.)
O. Support to someone NOT in household (Show name, age relationship (if
any) and address)
P. Any expense not shown above (Specify)

$
$
$
$

TOTAL $

0.00

Expense Remarks (Also explain any unusual or very large expenses, such as medical, college, etc.)

Form SSA-640 (11-2018)

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INCOME AND EXPENSES COMPARISON
11. A. Monthly income
Write the amount here from the "Grand Total" on #9
B. Monthly expenses
Write the amount here from the "Total" on #10

$

0.00

$

0.00

C. Adjusted Household Expenses

$

25.00

D. Adjusted Monthly Expenses (Add B and C)

$

25.00

12. If your expenses (D) are more than your income (A), explain how you are paying your bills

FOR SSA USE ONLY
Inc. Exceeds
Adj Expense

Inc. Less Than
Adj Expense

$
$
$
$

FINANCIAL EXPECTATION AND FUNDS AVAILABILITY
13. A. 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: a tax refund, pay raise or full repayment of
a current bill for the better- major house repairs for the
worse).

Yes (Explain in
Remarks space
below)

No

B. If there is an amount of cash on hand or in checking
accounts shown in item 5A, is it being held for a special
purpose?

No
Amount
on Hand

No (Money
Available for
any use)

Yes (Explain
in Remarks
space below)

C. Is there any reason you CANNOT convert to cash the
"Balance or Value" of any financial asset shown in item 5B?

Yes (Explain in
Remarks space
below)

No

D. Is there any reason you CANNOT SELL or otherwise
convert to cash any of the assets shown in items 6A and B?

Yes (Explain in
Remarks space
below)

No

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-640 (11-2018)

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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 PERSON OWING CMP
Printed Name (First name, middle initial, last name)

(Write in ink)

Date (MM/DD/YYYY)

Signature

Home Telephone Number (include area code)

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

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

City and State

Enter name of County (if any) in which you now
live

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.
Signature of Witness

Signature of Witness

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

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

Form SSA-640 (11-2018)

See Revised Privacy Act &
PRA Statements Attached

Page 8 of 9

Privacy Act Statement
Collection and Use of Personal Information
Sections 204 (a) and 1129, of the Social Security Act, as amended, and the Inspector General Act of 1978, 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.
We will use the information to make a determination regarding the payment of your Civil Monetary Penalty debt. We may also
share your information for the following purposes, called routine uses:
• To third party contacts such as private collection agencies and credit reporting agencies under contract with Social Security
Administration (SSA) and other agencies, including the Veterans Administration, the Armed Forces, the Department of the
Treasury, and State motor vehicle agencies, for the purpose of their assisting SSA in recovering program debt; and
• To third party contacts where the party contacted may have information needed to establish or verify information relevant
and necessary to a civil or administrative investigation by the Office of Inspector General (OIG) or in preparation for
proceedings pursuant to section 1128A of the Social Security Act, and "Civil Money Penalties."
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) 60-0094, entitled Recovery of
Overpayments, Accounting and Reporting/Debt Management System as published in the Federal Register (FR) on August 23,
2005, at 70 FR 49354 and the SSA, OIG's SORN OIG-002, entitled Civil and Administrative Investigative Files of the Inspector
General, SSA/OIG, as published in the FR on April 19, 1995, at 60 FR 19619 (duplicating and incorporating by reference Health
and Human Resources (HHS) system of records number 09-90-0100, entitled Civil and Administrative Investigative Files of the
Inspector General, HHS/OS/OIG, as published in the FR on September 30, 1982, at 47 FR 43190). 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 control
number. We estimate that it will take about 2 hours to read the instructions, gather the facts, and answer the questions. SEND
OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social
Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies
in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send
comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address, not the completed form.

Form SSA-640 (11-2018)

Page 9 of 9

Instructions for Completing the Form SSA-640 - Financial Disclosure for a Civil Monetary Penalty (CMP) Debt
When to Use this Form
This form is used to collect financial information from an individual who owes a CMP debt. SSA will use this information collected
in making decisions concerning repayment of the CMP.
EVIDENCE. When you file a request about how you will repay the CMP debt, you need to present any papers you have verifying
your financial statements. This would include items such as current bank statements, utility bills, pay stubs, credit card payments,
loan payments, etc. If you do not have these records immediately available, do not delay filing this form. You have up to 30 days
from filing your request concerning repayment of the CMP to supply them.
The following section explains how to complete the SSA-640. The SSA-640 along with supporting financial documentation should
be either returned to the address that is on the return envelope that was included with this form. If you have further questions
about the SSA-640, you may contact the SSA office that gave you this form.
HOW TO COMPLETE THE SSA-640 FORM:
A. Print the name of the person who owes the CMP debt.
B. Enter the Social Security Number of the person who owes the CMP debt.
YOUR FINANCIAL STATEMENT
1. - 3. Answer in all cases, filling in the narrative portions.
Members of Household
4. List your dependents who live with you regardless of relation.
ASSETS - Things You Have and Own
5. List for yourself and anyone listed in #4. Be sure to list both the balances and the income earned each month.
6. Be sure to list the vehicles and real property for both yourself and your household members.
Monthly Household Income
7. through 9. Read each question carefully, filling in the blanks with incomes for you, your spouse, and all other individuals
listed in #4. Make sure to list on a monthly basis. The note above question #5 tells you how to handle weekly, biweekly and
yearly amounts.
Monthly Household Expenses
10. List the total household expenses, again converting to monthly figures.
Please note that if you used a credit card to pay for any expenses, check the "CC" column for that expense. The expense
amount will reflect $0. Be sure to factor in the amount of your credit card payments under line F.
Income and Expenses Comparison
11. through 13. Complete as indicated.
Remarks: Use to continue answers to prior questions. Make sure to put the question number, to which you are referring, first. If
you need more space, continue on any blank sheet of paper.
Signature Of Person Owing CMP
Please be sure to sign and date, list your mailing address and the phone number(s) where we may reach you
Where to Send the Form
After you have completed and signed this form, fold it in thirds, insert it in the return envelope that came with the form and mail it.
Use the return envelope provided so that this form goes to the SSA office that is handling your request.