The interviewer will show the period and amount of the overpayment.

List the names and SSNs of the beneficiary (and the representative payee, if applicable). Complete items 1A and 1B.

Check the appropriate block(s) to indicate what type of relief the person is seeking.

Check block A if waiver is requested.

Check block B if the SVB recipient wants to repay the overpayment at a rate other than the lesser of 10 percent of the maximum SVB payment amount or the amount of the person’s monthly benefit.

Check block C if the person no longer receiving SVB wants to make installment repayments.

Secure a complete statement of why the person believed the overpaid monies were due, his/her understanding of the provisions involved in the overpayment and why the person believes he/she is without fault. Have the person explain any actions, conversations, notices or letters that affected his/her understanding of the law and reporting responsibilities.

If the person reported, get a description of what actions he/she took to report and what, if anything, he/she did after the report. If he/she did not report get an explanation of the person’s understanding of the reporting responsibilities in his/her own words. This question gives the person an opportunity to explain why he/she did not report a change. If the understanding is incorrect, explain the provisions, making sure the person understands. Document in the “Remarks” section or on a Report of Contact the person’s final understanding of his/her reporting responsibilities. Record this on the SSR. This should help to prevent additional overpayments and prevent later allegations of misinformation.

Use the response to this question in conjunction with information about past overpayments on the master beneficiary record (MBR), supplemental security record (SSR) and the folder, if available. It helps determine the overpaid person’s understanding of reporting responsibilities and the ability to recognize recurring and related events. Do not question the person’s veracity if our records show a prior overpayment that the person failed to report. Instead, ask questions that may help the person remember that a similar type of overpayment occurred and its relationship, if any, to the current circumstances. Give the person an opportunity to explain why he/she believes the current overpayment is different from the prior overpayment. If the person’s response is that he/she does not remember, record the answer.

The interviewer can help the person complete Section II if the person wants SSA assistance. However, if it is more expeditious or the person requests, Section II may be mailed to the person for completion and signature. Be sure to show the person’s name and the SSN under which the overpayment occurred. When a representative payee and a recipient are both liable for an overpayment (see VB 02005.110), collect separate Financial Statements from each.

Accept reasonable allegations about living expenses, income, assets, etc. When information appears incorrect or impossible and verification is needed, see GN 02250.250 for guidelines.

Collect answers to all questions in Section II unless the overpaid person is currently eligible to receive cash public assistance.

Do not complete questions 9-17 when the same information was recently obtained on a MSSICS redetermination form or other form signed as part of an SVB redetermination.

In order to determine eligibility for SSI, SSA must determine the value of an individual’s resources at the first moment of the month. Transferring ownership of a resource may affect the value of an SSI recipient’s countable resources, which in turn can affect SSI eligibility. Under the Foster Care Independence Act of 1999, (P.L. 106-169) effective 12/14/99, transferring ownership of a resource for less than fair market value can result in a period of ineligibility for SSI.

Therefore, when an SSI recipient requesting waiver of an SVB overpayment alleges that a resource has been transferred, (or a rep payee makes that allegation on the SSI recipient’s behalf), it is necessary to develop this issue in order to determine the effect on SSI eligibility in considering whether defeat the purpose applies based on SSI eligibility.

The answers should reflect the total monthly income of the waiver requester, regardless of whether the overpaid person is currently eligible for SSI or SVB. Use the current month’s income. When there is self-employment income, show one-twelfth of the anticipated net earnings for the year. Total assets should include all net resources of the waiver requester. Net resources are those remaining after the allowable exclusions are deducted.

This question helps you determine whether recovery with respect to that amount of the overpayment in the person’s possession will not defeat the purpose of the Title VIII (see VB 02005.325). Remember that possession of incorrectly made payments, (or proceeds from payments in identifiable liquid resources which accumulated during the overpayment period) means recovery will not defeat the purpose of Title VIII.

Self-explanatory

A person receiving SSI at the time the form is completed does not have to answer any more questions.

This item allows the waiver requester to list persons and describe his/her relationship (spouse, child, parent, friend, etc.) with those who live with AND depend on him/her for support.

See VB 02005.305C.5.f. Part A—Do not include the proceeds of any current month’s income listed in Question 14, such as cashing a paycheck to pay regular expenses (food, rent, etc.). That is, do not count the same money twice.

Part B—If the answers indicate that the person is receiving income from assets, include that income on line L of Question 14.

See VB 02005.305C.5.f.

See VB 02005.305C.5.f. Include the person’s income from all sources and the income of a spouse, if applicable. Indicate to whom the income belongs. Total each column to show household income. Convert all income to monthly totals: multiply weekly income by 13, then divide by 3; divide quarterly income by 3; divide yearly income by 12.

Show “cc” in the expense line if the expense (e.g., clothing) is also listed in line F (credit card payments). Show average monthly household expenses in the amount column. Household expenses are for all household members, not just overpaid person. Multiply weekly expenses by 13, then divide by 3; divide quarterly expenses by 3; divide yearly expenses by 12. Include in “Expense Remarks” any expenses unique to only one household member as well as any unusual or very large expenses.

Self-explanatory

The required explanation helps to determine if the person has any income or resources not shown on previous questions or if he/she is going into debt each month.

When item 16A exceeds item 16B, enter the difference in the top block. When item 16B exceeds item 16A, enter the difference in the lower block.

The answer will help determine if you should look beyond the immediate comparison of income and expenses from Question 16.