Get Ssa 632 F4

U.S. SSA Form ssa-ssa-632 SOCIAL SECURITY ADMINISTRATION Form Approved OMB No. 0960-0037 Request For Waiver Of Overpayment Recovery Or Change In Repayment Rate FOR SSA USE ONLY 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. ROAR Input Yes No Input Date Waiver 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* Approval Denial SSI AMT OF OP PERIOD DATES OF OP A. Name of person on whose record the overpayment occurred B. Social Security Number C. Name of overpaid person s making this request and his/her Social Security Number s Check any of the following that apply. Also Fill in the dollar amount in B C or D. A. unfair for some other reasons. B. I cannot afford to use all of my monthly benefit to pay back the overpayment. However I can withheld each month. afford to have C. D. I am no longer receiving Supplement Security Income SSI payments. I want to pay back each month instead of paying all of the money at once. I am receiving SSI payments. If we can t waive collection we may use this form to decide how you should repay the money. ROAR Input Yes No Input Date Waiver 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* Approval Denial SSI AMT OF OP PERIOD DATES OF OP A. If you are filling out this form for someone else answer the questions as they apply to that person* Approval Denial SSI AMT OF OP PERIOD DATES OF OP A. Name of person on whose record the overpayment occurred B. Social Security Number C. Name of overpaid person s making this request and his/her Social Security Number s Check any of the following that apply. Name of person on whose record the overpayment occurred B. Social Security Number C. Name of overpaid person s making this request and his/her Social Security Number s Check any of the following that apply. Also Fill in the dollar amount in B C or D. A. unfair for some other reasons. B. I cannot afford to use all of my monthly benefit to pay back the overpayment. Also Fill in the dollar amount in B C or D. A. unfair for some other reasons. B. I cannot afford to use all of my monthly benefit to pay back the overpayment. However I can withheld each month. afford to have C. D. I am no longer receiving Supplement Security Income SSI payments. However I can withheld each month. afford to have C. D. I am no longer receiving Supplement Security Income SSI payments. I want to pay back each month instead of paying all of the money at once. I am receiving SSI payments. If we can t waive collection we may use this form to decide how you should repay the money. ROAR Input Yes No Input Date Waiver 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* Approval Denial SSI AMT OF OP PERIOD DATES OF OP A. Name of person on whose record the overpayment occurred B. Social Security Number C. Name of overpaid person s making this request and his/her Social Security Number s Check any of the following that apply.