OVERPAYMENT/REPAYMENT DETAIL WORKSHEET

________________ County Department of Social Services	           Date: _____________

Client Name: ________________________________________  Case Number: ____________ 

AT ANY TIME, INCLUDING BEFORE YOU SIGN A CONFESSION OF JUDGMENT FOR AN OVERPAYMENT THAT WE SAY YOU OWE, YOU ARE ENTITLED TO ASK IF THE BALANCE THAT WE SAY YOU OWE IS CORRECT.   

You can ask DSS to report about recoupments and other kinds of repayments such as child support.  If DSS does not report a payment that you think was made, you can ask DSS about that payment.  

We may ask you to sign a Confession of Judgment (COJ).  Signing a Confession of Judgment is a serious matter.  If you sign a Confession of Judgment, and fail to make a payment within 90 days, we will file the judgment.  Once we have a judgment against you, we may be able to collect the debt that you owe from income or resources that you have, without going to court.

You are not required to sign a Confession of Judgment.  If you do not sign the confession of judgment, and we want to get a judgment against you for failure to make payments on your debt as agreed, we would have to take you to court in order to get a judgment.  
A judgment will be reflected on your credit record.

You are not required to sign any of these documents.  If you like, you may seek legal help before you decide if you want to sign a Confession of Judgment.  Free legal assistance may be available from _____________  Legal Aid at  phone # _____________.

I UNDERSTAND THAT I CAN ASK DSS TO REPORT TO ME ALL PAYMENTS MADE ON MY DEBT.

•	I HAVE ASKED FOR AN ACCOUNTING OF ALL PAYMENTS MADE ON MY DEBT. 
Sign full name: _______________________________  Date: ______

•	I AGREE WITH THE BALANCE AMOUNT ON MY DEBT AND I HAVE NOT ASKED FOR AN ACCOUNTING OF PAYMENTS MADE ON MY DEBT. 

Sign full name: ___________________________________  Date: ______

DSS REVIEWER SIGNATURE: _________________________________ Date: ______ 

Overpayment original amount $__________, for the period from __________ to ____________ .  The current balance  is $___________ .
 
(If more than one overpayment attach a separate sheet.) 

Possible Sources of Debt Reduction – Read BOTH Sides of This Form  

Child Support Collected and kept by DSS.  We have determined that: 
   ‪ Support was collected and considered in the overpayment(s) calculation. 
   ‪ Support was collected and not considered.  We will recalculate the overpayment(s).  
   ‪ No support was collected for any member of your case.

Recoupments.  We have determined that:
‪ Recoupments were taken and already considered. 
‪ Recoupments were taken but not considered.  We will recalculate your debt. 
‪ No amount was recouped for the overpayment(s) in question.

Interim Assistance (collection from your first SSI benefit).  We have determined that:
‪ Interim assistance payments were received and already considered. 
‪ Interim assistance payments were received but not considered.  We will recalculate your   debt. 
‪ Interim assistance was not collected for the period of the overpayments(s).
Lottery Offset:  We have determined that:
   ‪ A lottery offset payment was received and already considered.
   ‪ A lottery offset payment was received but not considered.  We will recalculate your debt.
   ‪ No lottery offset was received.

Lawsuit Settlement:  We have determined that:
   ‪ A lawsuit settlement is pending but no money has been collected by DSS *
   ‪ A lawsuit was settled and the payment was already considered.
   ‪ A lawsuit was settled and the payment was not considered.  We will recalculate your debt.
   ‪ We have no record of a pending lawsuit or lawsuit settlement.
*If you have a pending lawsuit but you repay public assistance before the lawsuit is settled, DSS cannot recover the amount you already repaid from your lawsuit settlement. 

Workfare (prior to 1997):  We have determined that:
   ‪ Workfare was done prior to 1997 but was already considered when we determined the amount of your overpayment(s).
   ‪ Workfare was done prior to 1997 but was not considered.  We will recalculate your debt.
   ‪ No workfare was done prior to 1997.

Other (for example; cash repayments; expired EBT benefits):  We have determined that: 
‪ There were no other repayments or collections that could have reduced the overpayment(s)
   ‪ The following repayments or collections were received: ____________________________
        _________________________________________________________________________.
 	‪ These repayments or collections were already considered.  
‪ These repayments or collections were not considered and your debt will be recalculated. 

Liens/ Mortgages on your house or property.  We have determined that:
‪ DSS does not have a lien or mortgage against your property. 
‪ DSS has a lien or mortgage against your property but no money has been collected.  **
	** If you own property and DSS has a lien or mortgage against that property, the lien or mortgage must be reduced by any amounts that you repay.

Tax Offset (This is when a state tax return is taken to repay a public assistance overpayment(s)) 
‪ A tax offset was taken and already considered in this overpayment(s) or was applied to a different overpayment(s).  
‪ A tax offset was taken but was not considered.  We will recalculate your overpayment.
‪ No tax offset was taken.

The following must be completed when a repayment source was not considered and the debt must be recalculated.  When DSS determines that the debt must be recalculated, NO Confession of Judgment can be gotten from the debtor until the recalculation is completed and the amount of the COJ is adjusted as appropriate.   

We have considered the following source(s) of potential repayment and recalculated your debt. ______________________________________________________________________________ 

______________________________________________________________________________. 

We have determined that the amount of your debt balance:
‪ Remains the same.  The balance is $ ___________ .
‪ Was incorrect and is reduced from $ ___________ to $ ___________.

DSS REVIEWER SIGNATURE: _________________________________ Date: ______