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Fillable Printable Form SSA-640

Fillable Printable Form SSA-640

Form SSA-640

Form SSA-640

Form SSA-640 (09-2012)
Destroy Prior Editions
SOCIAL SECURITY ADMINISTRATION
Financial Disclosure for Civil Monetary Penalty (CMP) Debt
Form Approved
OMB No. 0960-0776
Page 1
We will use this form to obtain financial information relating to the recovery of your
CMP debt.
Please print your answers to the questions on this form as completely as you can.
We will help you fill out the form if you want. If you are filling out this form for
someone else, answer the questions as they apply to that person.
FOR SSA USE ONLY
Input Date:
Amount of CMP$
Violation:
Title IITitle XVI
ACTION:
Approved $
Denied
A. Name of person who owes the Civil Monetary Penalty (CMP)
B. Social Security Number
YOUR FINANCIAL STATEMENT
Please answer all the questions as fully and completely as possible. We may ask to see some documents to
support your statements, so you should have them with you when you visit our office.
EXAMPLES ARE:
• Current Rent or Mortgage Books • 2 or 3 recent utility, medical, charge card, and
insurance bills
• Savings Passbooks • Checking Account Statements
• Papers showing you are receiving public • Similar documents for your spouse or dependent
assistance family members
• Your most recent Tax return • Pay stubs
Please write only whole dollar amounts- round any cents to the nearest dollar. If you need more space for
answers, use the "Remarks" section at the bottom of page 6.
1.
A. Did you lend or give away any property or cash after Yes No
notification of the CMP? (Answer Part B) (Go to question 2)
B. Who received it, relationship (if any), description and value:
2.
A. Did you receive or sell any property or receive any cash Yes No
(other than earnings) after notification of this CMP? (Answer Part B) (Go to question 3)
B. Describe property and sale price or amount of cash received:
3.
A. Are you now receiving cash public assistance? Yes No
(Answer Part B and C) (Go to question 4)
B. Name or kind of public assistance:
C. Claim Number:
Page 2
MEMBERS OF HOUSEHOLD
4.
List any person (child, parent, friend, etc.) who depends on you for support AND who lives with you.
NAMEAGE
RELATIONSHIP (if none, explain why
the person is dependent on you)
ASSESTS - THINGS YOU HAVE AND OWN
5.A. How much money do you and any person(s) listed in question 4 above have as cash
on hand, in a checking account, or otherwise readily available?
$
B. Does your name, or that of any other member of your household appear, either alone or with any other
person, on any of the following?
TYPE OF ASSETOWNER
BALANCE OR
VALUE
PER MONTH
SHOW THE INCOME (interest,
dividends) EARNED EACH
MONTH. (If none, explain in
spaces below. If paid quarterly,
divide by 3).
SAVINGS (Bank, Savings and
Loan, Credit Union)
$$
CERTIFICATES OF DEPOSIT (CD)$$
INDIVIDUAL RETIREMENT
ACCOUNT (IRA)
$$
MONEY OR MUTUAL FUNDS$$
BONDS, STOCKS$$
TRUST FUND$$
CHECKING ACCOUNT$$
OTHER (EXPLAIN)$$
TOTALS
$$
Enter the "Per Month" total on
line (k) of question 9.
6.A. If you or a member of your household own a car, (other than the family vehicle), van, truck, camper, motorcycle, or
any other vehicle or a boat, list below.
OWNER
YEAR, MAKE/
MODEL
PRESENT
VALUE
LOAN
BALANCE (if
any)
MAIN PURPOSE FOR USE
$$
$$
$$
Form SSA-640 (09-2012)
Page 3
6.
B. If you or a member of your household own any real estate (buildings or land), OTHER than where you live, or own
or have an interest in, any business, property, or valuables, describe below.
OWNERDESCRIPTION
MARKET
VALUE
LOAN
BALANCE (if
any)
USAGE-INCOME (rent, etc.)
$$
$$
$$
MONTHLY HOUSEHOLD INCOME
If paid weekly, multiply by 4.33 (4 1/3) to figure monthly pay. If paid every 2 weeks, multiply by 2.166 (2 1/6) If
self-employed, enter 1/12 of net earnings. Enter monthly TAKE HOME amounts on line A of question 9 also.
7.
A. Are you employed? Yes No
(Provide information below) (Skip to B)
Employer's name, address, and phone: (Write "self" if self-employed.)
Monthly pay before
deduction (Gross)
$
Monthly TAKE HOME
pay (NET)
$
B. Is your spouse employed? Yes No
(Provide information below) (Skip to C)
Employer's name, address, and phone: (Write "self" if self-employed.)
Monthly pay before
deduction (Gross)
$
Monthly TAKE HOME
pay (NET)
$
C. Is any other person listed in Question 4 employed?
Yes NAMES: No
(Go to question 8)
Employer's name, address, and phone: (Write "self" if self-employed )
Monthly pay before
deduction (Gross)
$
Monthly TAKE HOME
pay (NET)
$
8.
A. Do you, your spouse or any dependent member of Yes No
your household receive support or contributions from (Answer B) (Go to question 9)
any person or organization?
B. How much money is received each month?
(Show this amount on line (J) of question 9)
$
Source
Form SSA-640 (09-2012)
Page 4
9.
BE SURE TO SHOW MONTHLY AMOUNTS BELOW - If received weekly or every 2 weeks, read the instruction
directly above #7.
INCOME FROM #7 AND #8 ABOVE
AND OTHER INCOME TO YOUR
HOUSEHOLD
YOURSCHECKSPOUSESCHECK
OTHER
HOUSEHOLD
MEMBERS
CHECKSSA USE ONLY
A. TAKE HOME Pay (Net) (From #7,
A, B, C above)
$$$
B. Social Security Benefits
C. Supplemental Security Income
(SSI)
D. Pension(s) (specify type) (VA,
Military, Civil Service, Railroad, etc.)
E. Public Assistance
F. Food Stamps (Show full face
value of stamps received)
G. Income from real estate (rent,
etc.) (From question 6B)
H. Room and/or Board Payments
(Explain in remarks below)
I. Child Support/Alimony
J. Other Support (From #8(B) above)
K. Income From Assets (From
question 5)
L. Other (From any source, explain
below)
TOTALS $$$
Grand Total
(Add 3 total blocks above)
$
Remarks
Form SSA-640 (09-2012)
Page 5
MONTHLY HOUSEHOLD EXPENSES
If the expense is paid weekly or every 2 weeks, read the instruction on Page 3. Do NOT list an expense that is withheld from income
(Such as Medical Insurance). Only take home pay is used to figure income.
Show "CC" as the expense amount if the expense (such as clothing) is part of CREDIT CARD EXPENSE SHOWN ON LINE (F).
10.
$ PER
MONTH
SSA USE
ONLY
A. Rent or Mortgage (If mortgage payment includes property or other local taxes, insurance, etc.
DO NOT list again below.)
$
B. Food (groceries (include the value of food stamps) and food at restaurants, work, etc.)
C. Utilities (gas, electric, telephone)
D. Other Heating/Cooking Fuel (oil, propane, coal, wood, etc.)
E. Clothing
F. Credit Card payments (show minimum monthly payment allowed)
G. Property Tax (State and local)
H. Other taxes or fees related to your home (trash collection, water-sewer fees)
I. Insurance (life, health, fire, homeowner, renter, car, and any other casualty or liability policies)
J. Medical-Dental (after amount, if any, paid by insurance)
K. Car operation and maintenance (show any car loan payment in (N) below)
L. Other transportation
M. Church-charity cash donations
M. Church-charity cash donations (cont.)
M. Church-charity cash donations (cont.)
N. Loan, credit, lay-away payments (If payment amount is optional, show minimum)
O. Support to someone NOT in household (Show name, age, relationship (if any) and address)
P. Any expense not shown above (Specify)
TOTAL$
EXPENSE REMARKS (Also explain any unusual or very large expenses, such as medical, college, etc.)
Form SSA-640 (09-2012)
Page 6
INCOME AND EXPENSES COMPARISON
11.A. Monthly income
Write the amount here from the "Grand Total" on #9
$
B. Monthly expenses
Write the amount here from the "Total" on #10
$
C. Adjusted Household Expenses
+ $25
D. Adjusted Monthly Expenses ( Add B and C)
$
12.
If your expenses (D) are more than your income (A), explain how you are paying your bills
FOR SSA USE ONLY
INC. EXCEEDS $_______
ADJ EXPENSE +
INC. LESS THAN $_______
ADJ EXPENSE +
FINANCIAL EXPECTATION AND FUNDS AVAILABILITY
13.A. Do you, your spouse or any dependent member of your household expect your or
their financial situation to change (for the better or worse) in the next 6 months?
(For example: a tax refund, pay raise or full repayment of a current bill for the
better- major house repairs for the worse).
YES (Explain NO
in Remarks
space below)
B. If there is an amount of cash on hand or in checking accounts shown in item 5A,
is it being held for a special purpose?
YES
NO NO (Explain in
Amount (Money Remarks
on Hand Available space
For any use) below)
C. Is there any reason you CANNOT convert to cash the "Balance or Value" of any
financial asset shown in item 5B?
YES (Explain NO
in Remarks
space below)
D. Is there any reason you CANNOT SELL or otherwise convert to cash any of the
assets shown in items 6A and B?
YES (Explain NO
in Remarks
space below)
REMARKS SPACE - If you are continuing an answer to a question, please write the number (and letter, if any) of the question first.
Form SSA-640 (09-2012)
Page 7
PENALTY CLAUSE, CERTIFICATION AND PRIVACY ACT STATEMENT
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements
or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives 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 PERSON OWING CMP
PRINTED NAME (First name, middle initial, last name) (Write in ink)DATE (Month, Day, Year)
SIGN HEREHOME TELEPHONE NUMBER (Include area
code)
MAILING ADDRESS (Number and street, Apt. No., P.O. Box, or Rural Route)WORK TELEPHONE NUMBER IF WE MAY CALL
YOU AT WORK (Include area code)
CITY AND STATEZIP CODEENTER NAME OF COUNTY (IF ANY) IN WHICH
YOU NOW LIVE
Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the individual must sign below, giving their full addresses.
SIGNATURE OF WITNESS
ADDRESS (Number and street, City, State, and ZIP Code)
SIGNATURE OF WITNESS
ADDRESS (Number and street, City, State, and ZIP Code)
Privacy Act Statement - Collection and Use of Personal Information
Sections 204 (a), 205(a), 1129(c)(3) and 1129(e)(1), of the Social Security Act, as amended, authorize us to collect the information on this
form. We will use the information you provide to make a determination regarding the payment of the Civil Monetary Penalty (CMP) debt.
Your response is voluntary. However, failing to provide us all or part of the information could prevent an accurate and timely decision
on your request.
We rarely use the information you provide for any purpose other than for recovering your CMP debt. However, we may use it for the
administration and integrity of Social Security programs. In accordance with 5 U.S.C. § 552a(b) of the Privacy Act, however, we may
disclose information you provided on this form in accordance with approved routine uses, which include but are not limited to disclosures
to:
(1) Federal, foreign, State or local agency charged with the responsibility of investigating or prosecuting such violation or charged with
enforcing or implementing the statue, or rule, regulation or order issued pursuant thereto where such responsibility rests outside of OIG;
(2) Federal, State, or local agencies where disclosure is necessary in order to obtain records relevant and necessary to a civil or
administrative investigation of the Office of Inspector General;
(3) Third party contacts where the party contacted may have information needed to establish or verify information relevant and necessary
to a civil or administrative investigation by the OIG or in preparation for proceedings pursuant to section 1128A of the Social Security Act,
and "Civil Money Penalties;" and
(4) Federal, State, or local agencies, or to other entities administrating federally-funded programs where necessary to take action based on
an OIG investigation or audit which identifies individuals not entitled to program benefits or individuals delinquent on loan payments under
federall-funded programs.
We may also use the information you provide in computer matching programs. Matching programs compare our records with
records kept by other Federal, State or local government agencies. Information from these matching programs can be used to
establish or verify a person's eligibility for Federally funded and administered benefit programs and for repayment of payments
or delinquent debts under these programs.
We may also use the information you provide in computer matching programs. Computer matching programs compare our records with
those Federal, State, or local government agencies. We can use information from these matching programs to establish or verify a
person's eligibility for federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these
programs.
Complete lists of routine uses for this information are available in our System of Records Notices entitled, Recovery of Overpayments,
Accounting and Reporting/Debt Management System (ROAR/DMS), 60-0094; and OIG-002-Civil Administrative Investigative Files of the
Inspector General, 60 FR 19619 incorporating by reference HHS SORN 09-90-0100. These notices, additional information regarding this
form, and information regarding our programs and systems, are available on-line at //www.socialsecurity.gov or at your local Social
Security office.
Form SSA-640 (09-2012)
Page 8
Paperwork Reduction Act Statement
-This information collection meets the requirements of 44 U.S.C. § 3507, as
amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we
display a valid Office of Management and Budget control number. We estimate that it will take about 2 hours to read the
instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA's website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your telephone directory or
you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate
above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to
this address, not the completed form.
Instructions for Completing the Form SSA-640 – Financial Disclosure for a Civil Monetary Penalty (CMP) Debt
When to Use this Form
This form is used to collect financial information from an individual who owes a CMP debt. SSA will use the information
collected in making decisions concerning repayment of the CMP.
EVIDENCE: When you file a request about how you will repay the CMP debt, you need to present any papers you have
verifying your financial statements. This would include items such as current bank statements, utility bills, pay stubs,
credit card payments, loan payments, etc. If you do not have these records immediately available, do not delay filing this
form. You have up to 30 days from filing your request concerning repayment of the CMP to supply them.
The following section explains how to complete the SSA-640. The SSA-640 along with supporting financial
documentation should be either returned to the address that is on the return envelope that was included with this form. If
you have further questions about the SSA-640, you may contact the SSA office that gave you this form.
HOW TO COMPLETE THE SSA-640 FORM:
A. Print the name of the person who owes the CMP debt
B. Enter the Social Security Number of the person who owes the CMP debt.
YOUR FINANCIAL STATEMENT
1. – 3. Answer in all cases, filling in the narrative portions.
Members of Household
4. List your dependents who live with you regardless of relation.
Assets-Thing You Have and Own
5. List for yourself and anyone listed in #4. Be sure to list both the balances and the income earned each month.
6. Be sure to list the vehicles and real property for both yourself and your household members.
Monthly Household Income
7. through 9. Read each question carefully, filling in the blanks with incomes for you, your spouse, and all other
individuals listed in #4. Make sure to list on a monthly basis. The note above question #5 tells you how to handle weekly,
biweekly and yearly amounts.
Monthly Household Expenses
10. List the total household expenses, again converting to monthly figures.
Income and Expenses Comparison
11. through 13. Complete as indicated.
Remarks: Use to continue answers to prior questions. Make sure to put the question number, to which you are referring,
first. If you need more space, continue on any blank sheet of paper.
Signature Of Person Owing CMP
Please be sure to sign and date, list your mailing address and the phone number(s) where we may reach you.
Where to Send the Form
After you have completed and signed this form, fold it in thirds, insert it in the return envelope that came with the form and
mail it. Use the return envelope provided so that this form goes to the SSA office that is handling your request.
Form SSA-640 (09-2012)
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