Overpayment Waiver
Overpayment Waiver
IN ORDER TO RECEIVE A WAIVER OF YOUR OVERPAYMENT, YOU MUST PROVIDE INFORMATION TO SHOW THAT REPAYMENT OF THIS DEBT WOULD CAUSE EXTRAORDINARY HARDSHIP.
An extraordinary hardship is defined as an individual’s loss or inability to maintain minimal necessities of food, medicine and shelter. In making a financial hardship determination, the Division will take into account all income of the family household.
If you are requesting a waiver, please answer the following questions and acknowledge the form.
Fields marked with an asterisk (*) are required.
Contact Information
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Reason for BPC Overpayment Waiver
Explain the reason for the waiver request. (Define the hardship)
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List the names, ages and the social security number(s) for each family member in the household who are wage earners.
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List all outstanding debts and monthly expenses for the entire family household. For consideration, you must attach supporting documentation.
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List names and ages of all dependents.
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Have you secured work?
Please attach copy of supporting documentation.
Documentation Upload
File Types Allowed (.doc, .docx, .docm, xls, .xlsx, .txt, .pdf, .rtf, .snp)
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Notice Acknowledgement
Certification: I certify the information reported on this form is true and correct. I understand that if I intentionally make a false statement or misrepresent the facts on this form, I could be subject to criminal prosecution.
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