Form SSA-639 Expanded Monitoring Site Review Beneficiary Review Form

Form Approved
OMB No. 0960-0633

Social Security Administration

Expanded Monitoring Program
Site Review - Beneficiary Interview Form
Beneficiary Name

Beneficiary Telephone Number

Beneficiary SSN/Claim Number

Beneficiary Residence Address

Payee Name

Payee 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

FORM SSA-639 (07-2007)

Beginning Date

Ending Date

Amount

Frequency

Reason

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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:__________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
FORM SSA-639 (07-2007)

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REMARKS CONTINUED:

Interviewer's Name and Telephone Number

FORM SSA-639 (07-2007)

Date of Interview

Page 3

Privacy Act Statement
See Revised Privacy Act Statement Attached

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 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 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, not the completed form.

FORM SSA-639 (07-2007)

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SSA will insert the following revised Privacy Act Statement into the form at its next
scheduled reprinting:
Privacy Act Statement
Sections 205(j) and 1631(a) of the Social Security Act allows 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. The
information you furnish on this form is voluntary. However, without the information, we
will not be able to determine the performance of your payee and payment of your benefits
may be affected.
We rarely use the information you supply for any purpose other than for monitoring
the performance of your representative payee. We may, however, disclose the
information provided on this form in accordance with approved routine uses of the
Privacy Act (5 U.S.C. § 552a(b)), which include but are not limited to the following:
1.

To enable a third party or an agency to assist Social Security in
establishing rights to Social Security benefits and/or coverage;

2.

To make determinations for eligibility in similar health and
income maintenance programs at the Federal, State, and local
level;

3.

To comply with Federal laws requiring the disclosure of the
information from our records; and,

4.

To facilitate audit or investigative activities necessary to assure
the integrity of Social Security programs.

We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by other Federal, State, or
local government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally-funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Records
Notice 60-0222. This notice, additional information regarding this form, and
information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security Office.