TN 11 (08-91)
GN 02250.235 Completion of the Without Fault Statement, Section I of the SSA-632-BK
This section of the form is the basis for the fault determination in a waiver decision. The answers obtained here must thoroughly explain the overpayment situation. It is only completed when waiver is requested.
B. Procedure - Completion of Section I
1. Question 3
Complete if all or part of the overpayment was received by a representative payee. If there was no representative payee, check “no”.
2. Question 4
Complete only if a contingently liable person is protesting the recovery of another person's overpayment from his benefits. Have the person describe what he knew about the overpayment and why he is without fault.
If the contingently liable person was not living in the same household and is without fault, do not complete any more of the form. Recovery is against equity and good conscience (GN 02250.150). If he was not living with the overpaid person but is at fault, go to Section II.
3. Question 5
Obtain a complete statement of why the person believed the overpaid monies were due, his understanding of the provisions involved in the overpayment and why the person believes he is without fault. Have the person explain any actions, conversations, notices or letters that affected his understanding of the law and his reporting responsibilities.
4. Question 6
If the person reported, get a description of what actions he took to report and what, if anything, he did after the report. This response shows whether the person acted in good faith or exercised a high degree of care in complying with reporting responsibilities. If no report was made, get an explanation of the person's understanding of the reporting responsibilities in his own words. This question gives the person an opportunity to explain why he did not report any change of event. If the understanding is incorrect, explain the provisions, making sure the person understands.
Document in the “Remarks” section or on an RC the person's final understanding of his reporting responsibilities. This should help to prevent additional overpayments and prevent later allegations of misinformation.
5. Question 7
Use the response to this question in conjunction with information about past overpayments on the MBR, SSID, PHUS, ROAR records 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 opportunity to explain why he believes the current overpayment is different from the prior overpayment.