Enter the bankruptcy case number in this field. For example, 59-27467-csi. You will find the case number in section of the bankruptcy petition titled, "Information to identify the case."

Enter the last 4 digits of the individual's claim Social Security Number (SSN) and their beneficiary identification code (BIC). The Collection ID is for future use.

Enter the individual's full name and address.

Enter the individual's Beneficiary Notice Control Number (BNC) if applicable. The BNC is an encrypted 13 character alphanumeric code that we use to replace the SSN when applicable. Since this form is internal, including the BNC may not be necessary.

Enter the date, MM/DD/YYYY format, that you are completing this form where it says, "Total debt due to the United States as of." Enter the total debt amount owed in $999,999.99 format. If the individual has multiple outstanding debts, add each outstanding balance together and enter the total. For example, Jessie Lane has an outstanding debt balance of $5,250 for Debt 1, an outstanding debt balance of $700 for Debt 2, and an outstanding debt balance of $14,744 for Debt 3. Therefore, their total debt amount owed is $20,694 and this is the amount that you will enter in this field.

Enter the pertinent information regarding the overpayment/debt, in general terms, where it says, "The claim arose in connection with an overpayment of Social Security benefits." If the individual has multiple outstanding debts, enter the information regarding each debt, being brief, and stating the facts.

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  Include the appropriate section of the Act that applies for the overpayment, such as Section 204 of the Social Security Act;

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  Describe the payments made to a representative payee, if conserved benefits are involved, such as the amount(s) and the date(s) of the payments and the regulatory authority from which the claim arose, 20 CFR 404.2045;

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  Include information relating to a failure to report or any other material fact;

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  Include any administrative decisions, such as waiver denial or affirmation of the overpayment upon reconsideration and do not include SSA's attempts to collect the debt; and

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  Explain any adjustments or refunds which reduced the original overpayment amount(s).

Forward the completed form electronically to the appropriate executive or their designee for electronic signature. The PDF form allows for the signature based on the individual's PIV card.