If we have evidence that the overpaid individual knowingly supplied incorrect or incomplete information or knowingly concealed material facts, which directly or indirectly caused the overpayment, we will review the record to determine if there is a fraud conviction or similar fault determination. If the overpaid individual has a fraud conviction, similar fault determination, or civil monetary penalty, they are not eligible for a waiver of their overpayment and we will not make a waiver determination for these situations, refer to GN 02250.001E.

If there is no fraud conviction or similar fault determination, we may find the individual at fault for the overpayment, only after considering all the factors in GN 02250.005B.2. Refer to example 1 in GN 02250.021D.

If an individual incurred a past overpayment for the same reason as a current overpayment, review their record to determine if we documented that we informed them of the reason for the prior overpayment and their reporting responsibilities at the time of the prior overpayment. For procedures on reviewing an individual’s record, refer to GN 02250.021C. After reviewing the individual’s record and the pertinent circumstances surrounding the prior and subsequent overpayments, determine if they had adequate understanding of the obligation to report the change. Also, consider the amount of time that has passed since the prior overpayment occurred because the individual might not remember the reason for the prior overpayment or their reporting responsibility. Before making the fault determination, you must consider all the circumstances surrounding the overpayment, refer to GN 02250.005B.2. Refer to example 2 in GN 02250.021D.

If an individual alleges that they made a report to us or sent us information, check all available records. For procedures for checking an individual’s record, refer to GN 02250.021C. If an individual alleges making a report which is not in our files, document their allegation. For Title II cases, record their statement on the DMS Remarks screen. For Title XVI cases, obtain a statement on the Report of Contact Page in the Consolidated Claims Experience (CCE) or in a written statement on an SSA-5002, Report of Contact, for non-CCE cases. Upload the SSA-5002 into the electronic file or the Evidence Portal (EP). Make sure the statement includes what the individual remembers about reporting and what they expected would happen because of the report (e.g., benefits would terminate, we would notify only if benefits changed, etc.).

Before making the fault determination, you must consider the allegation as well as all the factors in GN 02250.005B.2.

We may find an individual not at fault for an overpayment if they misunderstood our policies on Title II entitlement or Title XVI eligibility or if they misunderstood information given to them. When determining whether an individual misunderstood our policies or information given to them, we must consider their age, comprehension, education, memory, physical and mental condition (which may include medical institutionalization during part or all of the overpayment period), and linguistic limitations. Refer to example 3 in GN 02250.021D.

Some policies that individuals commonly misunderstand for Title XVI overpayments include but are not limited to:

• •

  Gross pay (before taxes or deductions) versus net pay (take-home pay);

• •

  Reporting regular wages versus reporting all income;

• •

  How earned income for one individual may affect the SSI payment for others;

• •

  Excess resources; and

• •

  Change in living arrangements.

For more information on making fault determinations for Title II overpayments involving wages, refer to GN 02250.025.

Receipt of workers’ compensation (WC) or public disability benefits (PDB) can cause an offset to disability insurance benefits. When an individual alleges they did not know they needed to report receipt of these benefits, we must consider all circumstances surrounding the overpayment. To make the fault determination, review the records to determine if the individual signed an SSA-795, Statement of Claimant, agreeing to tell us about the WC or PDB and to repay any overpayment. To find the individual at fault, we must find evidence that:

1. a. 

   We clearly informed the individual of the duty to report the receipt of WC or PDB.

2. b. 

   The individual understood and should have remembered the reporting responsibilities; and

3. c. 

   The individual was able to report but did not attempt to report WC or PDB.

Given all the pertinent circumstances surrounding the overpayment, determine if the individual:

• •

  Had adequate knowledge of the effect of the change or event,

• •

  Understood their obligation to report the change, and

• •

  Attempted to report the change.

Refer to examples 4 and 5 in GN 02250.021D.

Before making the fault determination, you must consider the factors in GN 02250.005B.2. Refer to example 2 in GN 02250.021D.

Occasionally, the system will pay a duplicate check which bears the same date and the same amount (e.g., critical payment system (CPS) payments, substitute checks, courtesy disbursement, one-time payments.) To determine fault, consider if we gave the individual a notice explaining that they must return a check that they are not due and if the check stated, “Replaces CL dated (MM/DD/YY)”.

Consider if there are circumstances that may have prevented the individual from remembering they received a prior check. We must also consider if the overpaid individual:

• •

  understood they were not owed both checks,

• •

  understood the need to return the check, or

• •

  if they were able to read and understand the information on the check.

Before making the fault determination, you must consider the factors in GN 02250.005B.2

If an employee who worked for the railroad is alive, they can receive payments from both SSA and the Railroad Retirement Board (RRB). When the employee dies, only one agency (RRB makes the determination) will have jurisdiction over the survivor benefits, refer to RS 01601.300.

There are situations where an individual may receive survivor benefits from both Title II and RRB when they should only receive RRB benefits. We will find an individual not at fault if they were unaware that they should have received only one benefit. If we did not notify the individual that they were due only one benefit, we will find them not at fault. We will also find the individual not at fault if they did not understand that the benefits were not payable from both agencies.

Refer to examples 6 and 7 in GN 02250.021D.

Fault usually exists when an overpayment resulted from conditional payments based on excess non-liquid resources. We make such payments pursuant to a written agreement indicating full understanding of the consequences of disposition or failure to dispose the non-liquid resource.

However, before making the fault determination, you must consider the factors in GN 02250.005B.2. Ordinarily, this agreement is documented on a Form SSA-8060-U3 and faxed into the Evidence Portal (EP). If it is not in the EP, check the locations listed in GN.02250.021C. If you cannot locate the written agreement, and your review of the factors in GN 02250.005B.2 indicates the individual did not understand the agreement or the consequences of their failure to dispose of the resource, we will find the individual not at fault.

For information about conditional payments, refer to SI 01150.200 through SI 01150.206.

If an individual is overpaid because they received Goldberg Kelly payments, we may find them not at fault if they did not understand the Goldberg Kelly requirements, process, or that the payments may be incorrect. Before making the fault determination, you must consider the factors in GN 02250.005B.2

For information about Goldberg Kelly, refer to SI 02301.300.

If an individual is overpaid because they are incarcerated, we will base the fault determination on whether the individual knew or should have known their reporting responsibilities and if they had the ability to report. We must consider the factors in GN 02250.005B.2.

If an overpaid individual was overpaid because their representative payee failed to report a change to us, and the overpaid individual requests a waiver, we will consider only whether the overpaid individual was at fault. We cannot find the overpaid person at fault merely because the representative payee may have been at fault. We will find the overpaid individual not at fault, unless we find that the representative payee did not know of the change, and we find the overpaid individual:

• •

  was aware of the change;

• •

  understood the change could affect their benefits;

• •

  understood the responsibility of the representative payee to report the change to us;

• •

  knew the representative payee was unaware of the change; and

• •

  did not notify or attempt to notify the representative payee of the change.

In deciding whether the overpaid person is at fault, we must consider all the circumstances in GN 02250.005B.2.

If an overpayment is established due to representative payee misuse, and the misuse determination is upheld, the misuser is usually at fault.

For Title II instructions review these files:

• •

  Master Beneficiary Record (MBR),

• •

  Modernized Claims Systems (MCS),

• •

  Claims File User Interface (CFUI),

• •

  Evidence Portal,

• •

  Certified Electronic Folder (CEF),

• •

  Paper folder, if any, etc.

For Title XVI instructions review these files:

• •

  Supplemental Security Record (SSR),

• •

  CCE,

• •

  Claims File User Interface (CFUI)

• •

  Evidence Portal,

• •

  Certified Electronic Folder (CEF),

• •

  paper folder, if any, etc.