Form SSA-639 (revised) SSA-639 (revised) Expanded Monitoring Site Review Beneficiary Review Form

SSA-639 OMB NO. 0960-0633

Expanded Monitoring Program

Site Review - Beneficiary Interview Form

Beneficiary Name and Telephone Number:__________________________________

____________________________________________________________________

Beneficiary SSN/Claim Number: _________________________________________

Beneficiary Residence Address: _________________________________________

____________________________________________________________________

____________________________________________________________________

Payee Name and Address:________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Ask the beneficiary (or, if the beneficiary cannot respond, the custodian or other caregiver) the following questions:

1. Has the payee been paying your bills on time? [ ]Yes [ ]No If No, explain:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

2. Is the payee responsive to your needs? [ ]Yes [ ]No If No, explain: ________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

3. Have you ever asked the payee for money for a specific purchase and been denied?

[ ]Yes [ ]No If Yes, what was it that you needed and why did the payee tell you that you could not have it? ____________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

4. Does the payee ever give you any money, including cash, money orders, checks, or gift cards? [ ] Yes [ ]No If Yes, give:

Payment Method Beginning Date Ending Date Amount Frequency Reason

5. Does the payee charge you for any services? [ ]Yes [ ]No If Yes, give:

Service Beginning Date Ending Date Amount Charged Frequency

6. Have you ever asked the payee if you had any money saved and how much?

[ ]Yes [ ]No If Yes, what did the payee answer?________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

7. Do you know how to get in touch with the payee at all times? [ ]Yes [ ]No

If No, explain: ______________________________________________________ ___________________________________________________________________

__________________________________________________________________

8. Have you ever had difficulty trying to get in touch with the payee? [ ]Yes [ ]No

If Yes, explain: ____________________________________________________ __________________________________________________________________

__________________________________________________________________

9. Are you having any problems with the payee? [ ]Yes [ ]No If Yes, explain:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

• Note to Interviewer – Were any large or unusual expenses/purchases detected when you examined the representative payee’s records? If so, record and confirm here: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

REMARKS:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Interviewer’s Name and Telephone Number	Date of Interview:

Privacy Act Statement

Sections 205(j) and 1631(a) of the Social Security Act allow us to collect the information requested on this form. The information you provide will allow the Social Security Administration to monitor the performance of your representative payee. You do not have to give us this information. However, without the information, we will not be able to determine the performance of your payee and payment of your benefits may be affected.

Sometimes the law requires us to give out the facts you provide during this interview without your consent. We must release this information to another person or government agency if Federal law requires that we do so or to do the research and audit needed to administer or improve our representative payment program.

We may also use this information when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.

Explanations about these and other reasons why information you provide may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.

Paperwork Reduction Act Statement

This information collection meets the clearance 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 you about 10 minutes to read the instructions, gather the facts, and answer the questions. 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.

SSA-639 (Destroy Prior Editions)