SSA-637 (current version)

OMB NO. 0960-0633

Expanded Monitoring Program
Site Review Questionnaire for Volume Payees
(Do not use for fee-for-service payees)

Date of Review:

Field Office:

Payee/Organization Name and Address:

Name, title and phone number of organization's primary contact:

1. What type of payee/organization is this?

2. Number of people on your staff?
3. Number of SSA beneficiaries you serve?

4. Has the organization been independently audited within the last 2 years?

Yes

No

If "YES", can the organization provide the review team with a copy of the financial portion and
recommendations of the audit report?
Yes
No
If "NO", please explain.

5. Do you carry any type of employee dishonesty bond/insurance?

Yes

No

If "YES", in what amount?

Form SSA-637 (02-2005) ef (05-2005)

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6. How often and under what circumstances do you see/speak to the beneficiaries?

7. Do you ever disburse money directly to the beneficiary?

Yes

No

If "YES", under what circumstances (frequency, amounts, etc.)?

8. Do you take an active interest in assisting the beneficiary (i.e., seeking medical help, finding suitable
housing)?
Yes
No
If "YES", please describe.

9. Do you attempt to negotiate the best deals from landlords, grocers, banks, etc.?

Yes

No

If "YES", please describe.

10. Are benefits received via direct deposit?

Yes

No

11. Does the payee/organization hold the beneficiaries' funds in:
individual savings/checking accounts
collective savings/checking accounts

12. Does the account earn interest and is the beneficiary credited with the interest earned?
If "YES", please explain how the interest is credited.

Form SSA-637 (02-2005) ef (05-2005)

Yes

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No

Yes

13. Are you holding conserved funds in another account or by another method?

No

If "YES", please explain whether the conserved funds are in a burial account, mutual funds, property,
etc.

14. Were you required by SSA to establish a "dedicated" account for a minor child receiving SSI
benefits?
Yes
No
Yes

A. Do you continue to maintain funds in a dedicated account?

No

Note to Review Team: If payee maintains a dedicated account and the SSN was not
included in the review sample, ask the payee to provide a list of SSI beneficiaries
with dedicated accounts and review at least 1 case.
B. Were expenditures for medical treatment, or education or job skills training?
If "NO", please explain.

Yes

No

15. Did you receive any past-due (retroactive) benefits which were used to pay a past debt
owed to you?
Yes
No
If "YES", please explain if SSA approval was obtained.

16. Describe the accounting system used to monitor individual beneficiaries' funds (paper ledgers, computer
program).

17. Are the accounting records retrievable, orderly and clear?
If "NO", please describe.

Form SSA-637 (02-2005) ef (05-2005)

Yes

No

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18. Are the records accurate and up-to-date?

Yes

No

If "NO", please describe.

19. What process is used to report when someone is no longer in your care?

20. Any assistance/problems you need resolved by SSA?

REMARKS/OBSERVATIONS:

Reviewer's Name and Telephone Number

Date of Review

Total number of FO hours to perform review:

Form SSA-637 (02-2005) ef (05-2005)

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Privacy Act Statement
Sections 205(j) and 1631(a) of the Social Security Act allow us to collect the
information requested on this questionnaire. The information you provide will allow the
Social Security Administration to monitor your performance as a representative payee.
You do not have to give us this information. However, without the information, we will
not be able to determine if you are carrying out your representative payee duties and
responsibilities and you may no longer serve as a representative payee.
Sometimes the law requires us to give out the facts you provide during the site review
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 represenetative 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 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 (OMB) control
number. The OMB control number for this collection is 0960-0633. We estimate that it
will take about 1 hour to provide us with the information relative to the organization
and the functions it performs as representative payee for Social Security and
Supplemental Security Income beneficiaries. You may send comments on our time
estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address.

Form SSA-637 (02-2005) ef (05-2005)

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