About this form

This form is to be used to repay benefits overpaid by DCMWC as the result of death of the beneficiary or a change in the status of eligibility.

Please note that overpayment submissions should only be made if directed by DCMWC and the debtor has all information specific to the overpayment. Overpayment submissions without the valid information will be rejected.

Accepted Payment Methods:

• Bank account (ACH)
• Debit card