Form SSA-632-BK (09-2023) UF 
Discontinue Prior Editions                                                  Page 1 of 10 
Social Security Administration                                              OMB No. 0960-0037

               Request for Waiver of Overpayment Recovery

When To Complete This Form
Complete this form if any of the following applies:

      You think that you are not at fault for the overpayment and you cannot afford to pay the money back.
    • 

    • You think that you are not at fault and you think the overpayment is unfair for some other reason.

We will use your answers to decide if you have to pay the money back. If we decide you do not have to pay 
the money back, we call it a waiver. 

When Not To Complete This Form

    • You think that you are not at fault and your overpayment is $1,000 or less. Instead, please request a 
      waiver by calling 1-800-772-1213 or your local field office. We may be able to process your request 
      quickly over the phone.

    • You think we made a mistake when we decided that you were overpaid, or if you disagree with the 
      amount of your overpayment. Instead, please complete the SSA-561, Request for Reconsideration.

    • You are requesting a hearing before an Administrative Law Judge. Instead, please complete the 
      HA-501-U5, Request for Hearing by Administrative Law Judge. 

    • You only want to change the amount of money you must pay us back each month. Instead, please 
      complete the SSA-634, Request for Change in Overpayment Recovery Rate.

    • You have been convicted of fraud relating to this overpayment.

IMPORTANT: Please answer the following questions as completely as you can and submit any supporting 
documents with your waiver request. If you are assisting the person who is requesting a waiver, please 
answer the questions as if that person was completing the request. If you need more space for answers, use 
the "REMARKS" section on page 7. 

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. If you are filling out the waiver request for the overpaid person, provide your name and relationship 
      to the person.

     Name:

     Relationship:

Form SSA-632-BK (09-2023) UF                                                                         Page 2 of 10

SECTION 2 - WAIVER REQUEST

2.   Is the total amount of the overpayment stated on your letter $1,000 or less?                Yes No
     If Yes, you do not need to complete the rest of this form. Please call 1-800-772-1213 or your local field 
     office and we may be able to process your waiver request quickly over the phone.  
     If No, continue completing the rest of the form.
     What is your reason for requesting a waiver? (Check all that apply)
     A.    The overpayment was not my fault.
     B.    I cannot afford to pay the money back.

     C.    The overpayment is unfair for other reasons.
           Please explain:

3.   Please provide the date of the notice for the overpayment that you are asking us to waive: 
                                      (MM/DD/YYYY)

4.   Are you requesting that we waive the entire overpayment, including money that you have already paid 
     back to us? Yes         No

     If No, are you requesting that we only waive the remaining amount of money                                     
     that you owe us?  Yes      No
5.   Tell us what you know about why the overpayment may have happened. If there was a reason you did 
     not understand or were not able to report the change to us, please explain why.  
     Overpayments typically occur when a change happened in your life that we think we did not find out about on time. This 
     happens for many reasons and understanding your opinion helps us decide your waiver request.

SECTION 3 - NEEDS BASED INCOME

6.   Are you currently receiving SSI payments?       Yes    No
     If Yes, go to page 9, sign, date, and provide your address and phone number.  
     If No, complete the rest of the form.

7.   A dependent is a person who depends on you for support and whom you can claim on your tax return. 
     If you have a Title II overpayment, are you or any dependent household member currently receiving 
     any of the following?  
           • Supplemental Security Income (SSI) payments 
           • Temporary Assistance for Needy Families (TANF) 
           • Pension based on need from the Department of Veterans Affairs (VA)
        Yes      No

     If Yes, go to page 9, sign, date, and provide your address and phone number. Please, provide proof 
     of the TANF or VA pension. 
     If No, complete the rest of the form.

Form SSA-632-BK (09-2023) UF                                                                  Page 3 of 10

SECTION 4 - MEMBERS OF HOUSEHOLD
 8.  A. If you are an adult requesting a waiver, list your spouse and dependents in this section. A 
       dependent is a person who depends on you for support and whom you can claim on your income 
       tax return. Complete Sections 5, 6 and 7 with your, your spouse's, and dependents' information.
       If you are completing the waiver request for a minor child, does the child's income and assets help 
       with food and household items? 
        
        • If Yes, list the minor child's parent (s) and other dependents' of the parents in this section. 
        Complete Sections 5, 6 and 7 with the entire household's information. 
        
        • If No, only provide the child’s information in Sections 5, 6 and 7.
                             Name                   Age                  Relationship To You

     B. Does any adult or child live with you whom you cannot claim as a dependent on your tax return?
        Yes     No

       Does this person pay any rent, household bills, or any other household expense?
        Yes, total monthly amount you receive $                              No
Documents to Support Your Statement:   
To complete Sections 5, 6 and 7 of this form, you should refer to certain documents to support your 
statements. Please answer all the questions and submit any supporting documents for you, your spouse, 
and your dependents. Your supporting documents should be dated no more than 3 months from the date 
that you are requesting a waiver. Examples of supporting documents are: 
 
     • Current Rent or Mortgage Information                              • Recent Bank Statements 
     • 2 or 3 Recent Utility, Medical, Charge Card, and Insurance Bills  • Current Pay Stubs         
     • Your Most Recent Income Tax Return                                • Canceled Checks           

SECTION 5 - ASSETS - THINGS YOU HAVE AND OWN

 9.  A. How much cash do you, your spouse, and your dependents have in your possession?  $
     B. List all financial accounts for you, your spouse, and your dependents. 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. 
                                                                        Income Per Month  
     Type of   Name and Address of     Name on   Balance or 
                                                                         (interest or     Account Number
     Account    Institution            Account     Value
                                                                         dividends)

                                                 $                      $

                                                 $                      $

                                                 $                      $

                                                 $                      $

                                                 $                      $

                                          TOTALS $                      $

Form SSA-632-BK (09-2023) UF                                                           Page 4 of 10

10.  A. Do you, your spouse, or your dependents 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 of the vehicles below)       No (go to 10.B)
                                                                 Loan Balance 
     Owner                   Year, Make/Model Present Value                    Main Purpose for Use
                                                                   (if any)

                                              $                  $

                                              $                  $

                                              $                  $

                             TOTALS $

     B. Do you co-own any real estate with anyone other than your spouse or dependent family member?
     Yes (list below)                           No (go to 10.C)
                                                                 Loan Balance 
     Owner                   Description      Market Value                       Income Amount
                                                                   (if any)

                                              $                  $            $

                                              $                  $            $

                                              $                  $            $

                             TOTALS $

     C. Do you, your spouse, or your dependents own or have an interest in any business, property, or valuables?
     Yes (list below)                           No (go to 11)
                                                                 Loan Balance 
     Owner                   Description      Market Value                       Income Amount
                                                                   (if any)

                                              $                  $            $

                                              $                  $            $

                                              $                  $            $

                             TOTALS $

     D. Can you sell or liquidate any of the assets listed above?
     Yes, explain                                                              No

Form SSA-632-BK (09-2023) UF                                                               Page 5 of 10

SECTION 6 - MONTHLY HOUSEHOLD INCOME

Enter your, your spouse's, and your dependents' monthly take home pay. Enter the amount on line 12.A. If 
you need more space for answers, use the "REMARKS" section on page 7. 

11. A. Are you employed?         Yes (provide information below)            No (go to 11.B)

     Employer(s) Name, Address, and Phone: (Write "self" if self-employed) Monthly take home pay or 
                                                                           earnings if self-employed:

                                                                           $

     B. Is your spouse employed?      Yes (provide information below)       No (go to 11.C)

     Employer(s) Name, Address, and Phone: (Write "self" if self-employed) Monthly take home pay or 
                                                                           earnings if self-employed:

                                                                           $

     C. Are any of your dependents employed, including self-employment?
      Yes (provide information below) No (go to 12)
     Name(s) of dependents:

     Provide total monthly take home pay for dependent(s):
     $

Form SSA-632-BK (09-2023) UF                                                       Page 6 of 10

12.
     Income                                                                        Dependent(s) of 
                                                 Overpaid person's   Spouse of  
     (Be sure to show monthly                                                      Overpaid Person 
                                                   income          Overpaid Person
     amounts below)                                                                (Total)

     A. Take Home Pay (Net)                    
     (from questions 11.A, 11.B,                 $                 $              $
     and 11.C)

     B. Social Security Benefits 
     (retirement, disability, widows,            $                 $              $
     students, etc.)

     C. Supplemental Security       
                                                 $                 $              $
     Income (SSI)

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

     E. Supplemental Nutrition 
     Assistance Program (SNAP)                   $                 $              $
     Benefits
     F. Income from Real Estate, 
     Business, etc.                              $                 $              $
     (from questions 10.B and 10.C)

     G. Room and/or Board Payments 
     from a Person who is not a 
     Dependent (from question 8.B).  $                             $              $
     Put the amount in the overpaid 
     person's column.

     H. Child Support/Alimony                    $                 $              $

     I. Support or contributions from any 
                                                 $                 $              $
     person, agency, or organization

     J. Income from Assets                       
                                                 $                 $              $
     (from question 9.B)

     K. Other (from any source, explain 
                                                 $                 $              $
     in "REMARKS" on page 7)

                                TOTALS:          $                 $              $

                             Grand Total $

Form SSA-632-BK (09-2023) UF                                                                  Page 7 of 10

SECTION 7 - MONTHLY HOUSEHOLD EXPENSES 
Do not list an expense that is withheld from your paycheck (such as medical insurance, child support, 
alimony, wage garnishments, etc.).

                              Type of Expense                                                 $ Per Month
13.  A. Rent or Mortgage (if mortgage payment includes property or other local 
                                                                                             $
      taxes, insurance, etc., DO NOT list it again below)
     B. Property Tax (State and local) (if included in mortgage payment, do not list 
                                                                                             $
      it again)
     C. Utilities (gas, electric, telephone (cell or land line), Internet, trash collection, 
                                                                                             $
      water, sewer, oil, propane, coal, wood, etc.)
     D. Insurance (life, health, fire, homeowner, renter, car, and any other   
                                                                                             $
      casualty or liability policies)
     E. Food (groceries, including food purchased with SNAP benefits, and food at 
                                                                                             $
      restaurants, work, etc.)
     F. Household and Personal Care Items (clothing, cleaning items, toiletries, 
                                                                                             $
      salon visits, pet supplies, etc.)
     G. Expenses for Family Vehicle (loan, lease, gas, and repairs)                          $

     H. Other Transportation (bus, taxi, etc.)                                               $
     I. Medical/Dental (prescriptions and medical equipment, if not paid                
                                                                                             $
      by insurance)
     J. Tuition and School Expenses                                                          $

     K. Court Ordered Payments Paid Directly to the Court                                    $
     L. Credit Card Payments (show minimum monthly payment).                             
                                                                                             $
      DO NOT include any expenses already listed above

                                                                    TOTAL                    $

If you are not paying your bills, explain which bills have unpaid balances in the "REMARKS" section below.

REMARKS SECTION

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

IMPORTANT: Please review, complete, and sign the statements on pages 8 and 9.

Form SSA-632-BK (09-2023) UF                                                                     Page 8 of 10

Below is an authorization for the Social Security Administration to obtain your financial account information. 
We may need to access your financial records in order to determine if we can waive your overpayment.  
  
IMPORTANT: If the overpaid individual is a minor child, a parent or legal guardian must complete and sign 
the form on the child's behalf. If a court has assigned a legal guardian to an adult individual, the legal 
guardian must complete and sign the form. Adults who do not have a court appointed legal guardian must 
complete and sign the form, even if they have a representative payee. 

AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN ACCOUNT RECORDS 
FROM A FINANCIAL INSTITUTION AND REQUEST FOR RECORDS

Please review the following, make selection, and sign below: 
I understand:
  · I have the right to revoke this authorization at any time before any records are disclosed; 
  · The Social Security Administration may request all records about me from any financial institution; 
  · Any information obtained will be kept confidential; 
  · I have the right to obtain a copy of the record which the financial institution keeps concerning the 
     instances when it has disclosed records to a government authority unless the records were disclosed 
     because of a court order; 
  · This authorization is not required as a condition of doing business with any financial institution.  
  · The Social Security Administration will request records to determine the ability to repay an 
     overpayment in conjunction with a waiver determination; 
  · Failing to provide or revoking my authorization may result in the Social Security Administration 
     determining, on that basis, that adjustment or recovery of the overpayment will not deprive me of 
     funds to pay my bills for food, clothing, housing, medical care, or other necessary expenses; 
  · This authorization is in effect until the earliest of: 1) a final decision on whether adjustment or 
     recovery of my overpayment would deprive me of funds to pay my bills for food, clothing, housing, 
     medical care, or other necessary expenses; or 2) my revocation of this authorization in written 
     notification to the Social Security Administration. 

  I authorize any custodian of records at any financial institution to disclose to the Social Security 
  Administration any records about my financial business or that of the person named above whom I 
  legally represent or whose benefits I manage.

  I do not authorize any custodian of records at any financial institution to disclose to the Social 
  Security Administration any records about my financial business or that of the person named 
  above whom I legally represent or whose benefits I manage. I understand that if I do not give 
  permission to obtain financial records or if I cancel my permission, SSA may not approve my 
  waiver request. 

Customer's Signature/Authorization           Mailing Address                        Date

Legal Representative's                       Legal Representative's Mailing Address Date
Signature/Authorization

Form SSA-632-BK (09-2023) UF                                                  Page 9 of 10

     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, REPRESENTATIVE PAYEE,  
                             LEGAL GUARDIAN, or CUSTODIAL PARENT

Signature (First name, middle initial, last name)            Date (MM/DD/YYYY)

Home Telephone Number (include area code)              Cell Phone Number

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                                2. Signature of Witness

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

Form SSA-632-BK (09-2023) UF                                                                      Page 10 of 10

                                      Privacy Act Statement 
                             Collection and Use of Personal Information

Sections 204 and 1631 of the Social Security Act, as amended, allow us to collect your information or the 
information you are submitting on behalf of another, which we will use to make a waiver determination on an 
overpayment and to obtain authorization for financial account information.  Providing this information is 
voluntary, but not providing all or part of the information may prevent us from assisting you with the request.  
As law permits, we may use and share the information you submit, including with other Federal agencies, 
employers, third party contacts, and others as outlined in the routine uses within System of Records Notices 
(SORN) 60-0094, 60-0103, and 60-0320, available at www.ssa.gov/privacy.  The information you submit 
may also be used in computer matching programs to establish or verify eligibility for Federal benefit 
programs and to recoup debts under these programs.

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 60 minutes 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 regarding this burden estimate or any 
other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, 
Baltimore, MD 21235-6401.  Send only comments relating to our time estimate or other aspects of 
this collection to this address, not the completed form.