Request for Waiver Of Overpayment, Recovery Or ... - Social Security

REMARKS SPACE (Continued)PENALTY CLAUSE, CERTIFICATION AND PRIVACY ACT STATEMENTI declare under penalty of perjury that I have examined all the information on this form, and on any accompanyingstatements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowinglygives a false or misleading statement about a material fact in this information, or causes someone else to do so,commits a crime and may be sent to prison, or may face other penalties, or both.SIGNATURE OF OVERPAID PERSON OR REPRESENTATIVE PAYEESIGNATURE (First name, middle initial, last name) (Write in ink) DATE (Month, Day, Year)SIGNHEREMAILING ADDRESS (Number and street, Apt. No., P.O. Box, or Rural Route)HOME TELEPHONE NUMBER (Include area code)( ) -WORK TELEPHONE NUMBER IF WE MAY CALL YOU ATWORK (Include area code)( ) -CITY AND STATESIGNATURE OF WITNESSZIP CODEWitnessesarerequiredONLYifthisstatementhasbeensignedbymark(X)above.Ifsignedbymark(X),twowitnesses to the signing who know the individual must sign below,giving their full addresses.-SIGNATURE OF WITNESSENTER NAME OF COUNTY (IF ANY) IN WHICH YOUNOW LIVEADDRESS (Number and street, City, State, and ZIP Code)ADDRESS (Number and street, City, State, and ZIP Code)Privacy Act StatementCollection and Use of Personal InformationSections 204, 1631(b), and 1870 of the Social Security Act, as amended,and the Federal Coal Mine Health and Safety Act of 1969 authorize us tocollect this information. The information you provide will be used to makea determination on waiving overpayment recovery or changing yourrepayment rate.The information you furnish on this form is voluntary. However, failure toprovide the requested information may prevent us from approving yourrequest.We rarely use the information you supply for any purpose other than fordetermining waiver or a change in the repayment rate of an overpaymentrecovery. However, we may use it for the administration and integrity ofSocial Security programs. We may also disclose information to anotherperson or to another agency in accordance with approved routine uses,which include but are not limited to the following:To enable a third party or an agency to assist Social Security inestablishing rights to Social Security benefits and/or coverage; To complywith Federal laws requiring the release of information from Social Securityrecords (e.g., to the Government Accountability Office and Department ofVeterans' Affairs);To facilitate statistical research, audit or investigative activities necessary toassure the integrity of Social Security programs; and To the Department ofJustice when representing the Social Security Administration in litigation.We may also use the information you provide in computer matchingprograms. Matching programs compare our records with records kept byother Federal, state or local government agencies. Information from thesematching programs can be used to establish or verify a person's eligibilityfor Federally funded or administered benefit programs and for repayment ofpayments or delinquent debts under these programs.Additional information regarding this form, routine uses of information, andour programs and systems, is available on-line at www.socialsecurity.govor at your local Social Security office.Paperwork Reduction Act Statement - This information collectionmeets the requirements of 44 U.S.C. § 3507, as amended by section 2 ofthe Paperwork Reduction Act of 1995. You do not need to answer thesequestions unless we display a valid Office of Management and Budgetcontrol number. We estimate that it will take about 2 hours to read theinstructions, gather the facts, and answer the questions. SEND ORBRING THE COMPLETED FORM TO YOUR LOCAL SOCIALSECURITY OFFICE. To find the nearest office, call 1-800-772-1213(TTY 1-800-325-0778). Send only comments on our time estimateabove to: SSA, 6401 Security Blvd.,Baltimore,MD21235-6401.Form SSA-632-BK (05-2009) ef (05-2009) Page 8