Form SSA-637 Expanded Monitoring Site Review Questionnaire for Volume

Form Approved
OMB No. 0960-0633

Social Security Administration

Expanded Monitoring Program
Site Review Questionnaire for Volume and Fee for Service Payees
Pre-visit Background Information for SSA Use
(Complete Prior to Visit)

[ ] Check if random review
Organization/Agency/Payee/Name:

Part 1 – Pre-visit Information to Ask Payee
1. Date and time site visit scheduled for (Send confirmation letter.):
2. Address(es) to be visited:

3. Name, title and phone number of primary contact:
4. Name, title and phone number of alternate contact:
5. What is the name of the person responsible for each of the following representative payee workloads?
(Include the individual’s title and phone number if not the same person named in question 3 or 4.)
Receiving and posting benefits to ledgers:
Completing annual accounting forms:
Paying beneficiaries’ bills:
Determining beneficiary needs:
Monitoring resource limits:
Administering dedicated accounts:
Reporting changes to SSA:
Completing SSA forms:
Reconciling bank statements:
Internal audits of beneficiary accounts:
6. Will the responsible staff be available during site visit?

[ ] Yes [ ]No

If “No,” explain:

7. Can you send in a list of beneficiaries served including their SSNs, their current residence addresses, daytime
phone numbers, and conserved fund balances; and a copy of any internal written guidelines for managing
beneficiary funds; and a copy of a sample financial ledger including a key for reading any codes on the
ledger? [ ] Yes [ ]No
If “No,” explain:

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Part 2 – Information from SSA Records
8. Are the payee’s mailing and location addresses and phone number on the Representative Payee System (RPS)
correct?
[ ]Yes
[ ]No
If “No,” explain and direct the servicing FO to correct RPS:

9. Is the payee listed more than once on the ZIPL screen(s) on RPS? [ ]Yes

[ ]No

If “Yes,” explain the error and direct the servicing FO to correct the problem:

10. Is the payee an organization?

[ ]Yes

[ ]No

If “Yes,”:
(a) Enter TOP from RPS (OIRL screen):
(b) Does TOP code match the actual type of payee?

[ ]Yes

[ ]No

If “No,” explain the error and direct the servicing FO to correct RPS:

11. Enter the total number of Social Security/Supplemental Security Income (SSI) beneficiaries the payee serves
from the OILM screen in RPS:
12. See question 7. Is the conserved fund balance of any SSI beneficiary more than $2,000 ($3,000 for a
couple)?
[ ]Yes

[ ]No

[ ]Balances not submitted

If “Yes,” list the beneficiaries below and in question 14 to include in the beneficiary sample. You must
determine if an excess resource issue exists for these beneficiaries during the site review (See question 87).

13. Does the payee have any overdue annual accounting reports? (Ask the servicing FO to check the Title II and
Title XVI nonresponder lists for overdue annual accounting forms.)
Yes [ ] No[ ]
If “Yes,” list the names and SSNs of the beneficiaries below and list some of them in question 14 to
include in the beneficiary sample. Resolve the annual accounting report problem with the payee during
the site review (See question 56).

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14. List the names and SSNs of beneficiaries selected for the review sample:

15. Does the payee’s list of beneficiaries served and their residence addresses agree with SSA records?
(Compare the list requested in question 7 to the list of beneficiaries currently served on RPS. To check
residence addresses, begin by checking the residence addresses on RPS and the SSR for beneficiaries in the
sample.) [ ]Yes
[ ]No
If “No,” resolve the discrepancy and remedy any reporting problem during the site review. (See
question 57).
16. Is the payee fee for service (FFS)?

[ ]Yes

[ ]No

If “Yes”:
(a) Print a copy of the RFEE screen from RPS and have it available at the site review.
(b) Does the payee continue to serve at least 5 beneficiaries? (See answer to question 11.)
[ ]Yes

[ ]No

(c) When was the most recent annual certification (see RFEE screen)?
17. Do SSA records (MBR/SSR) show that the payee uses direct deposit?

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[ ] Yes

[ ]No

18. Does RPS (RPPR screen) have a collective account precedent? [ ]Yes

[ ]No

19. Were any problems noted during the last review? (If the prior report is not available from the servicing FO
or RO, check RPS or the Philadelphia Representative Payee Monitoring website for information about the
results.)
[ ] Yes [ ] No
If “Yes,” list the problems:

20. Since the last review (or since appointment as payee, if no prior review) has the servicing FO received any
complaints or have concerns about this payee’s performance?
[ ] Yes
[ ] No
If “Yes,” list the complaints and/or concerns:

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Expanded Monitoring Program
Site Review Questionnaire for Volume and Fee for Service Payees
Site Review Interview Guide
(Complete During Visit)
Date of Review:

Servicing Field Office:

Lead Reviewer’s Name:

Lead Reviewer’s Phone Number:

Part 3 – Meeting Information
Information from SSA reviewer:
21. List SSA Meeting Participants:

Information from payee:
22. List Payee Meeting Participants (Include title and phone number, if not listed in question 5):

Part 4 – External Audits
Information from payee:
23. Have you been independently audited within the last 2 years? [ ]Yes

[ ]No (go to Part 5.)

24. Can you give us a copy of the most recent audit report and any response you may have made?
[ ]Yes [ ]No
If “No,” explain:

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Information from SSA reviewer:
25. Do the audit results have a bearing on this site review? [ ]Yes

[ ]No

If “Yes,” explain (e.g., payee not solvent, poor recordkeeper):

Part 5 – Licensing (Complete this Part only if the payee is nongovernmental FFS, otherwise go to Part 7.)
Information from payee:
26. Is your organization licensed? [ ]Yes

[ ]No

If “Yes,” provide SSA with a copy of the license.
If “No,” explain (e.g., licensing not available in jurisdiction, license expired):

Information from SSA reviewer:
27. Does the payee continue to meet licensing requirements?

[ ]Yes

[ ]No

If “Yes,” update the RFEE screen on RPS.
If “No,” explain why not and update the RFEE screen on RPS.

Part 6 – Bonding (Complete this Part only if the payee is nongovernmental FFS.)
Information from payee:
28. Is your organization bonded? [ ]Yes

[ ]No

If “Yes,” provide SSA with a copy of the bond.
If “No,” explain:

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Information from SSA reviewer:
29. If the payee is bonded, calculate the minimum required bond amount for this payee:
a. Average amount of social security and SSI benefits received in one month: $
b. Amount of conserved funds on hand:

$

c. Add a. and b. for minimum required bond amount for this payee:

$

30. If the payee is bonded, is the bond amount sufficient to cover the number of beneficiaries the payee serves?
(Minimum coverage must equal or exceed the amount in 29.c.) [ ]Yes [ ]No
31. Does the payee continue to meet bonding requirements? [ ]Yes [ ]No
If “Yes,” update the RFEE screen on RPS.
If “No,” explain why not and update the RFEE screen on RPS:

Part 7 – Fee Charging

(Ask all payees these fee charging questions.)

Information from payee:
32. a. Do you charge a fee to beneficiaries directly for payee services or for any other service you provide
(e.g., SSA-approved FFS, fee deducted from personal needs allowance of institutionalized
beneficiaries, fee for administrative expenses)? [ ]Yes
[ ]No
b. If “Yes,” list:
Beginning
Date

Frequency
(e.g., monthly, weekly)

Reason
for Fee

How Fee Determined or
Fee Amount

33. a. Have you collected fees from beneficiaries for past months from either current or retroactive
benefits? [ ]Yes
[ ]No

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b. If “Yes,” list:
Beginning and
Ending Dates

Amount

Frequency
(e.g., monthly, weekly)

Reason for Fee

34. Do you collect a fee or receive a payment for services from any source other than the beneficiaries (e.g.,
court or guardianship fees, fees from a State agency for providing services to the beneficiary)?
[ ]Yes

[ ]No

If “Yes,” list:
Beginning Date

Amount

Frequency
(e.g., monthly, weekly)

Reason for Fee

35. If you charged any fees, have you waived fees whenever monthly living expenses exceeded the amount of
the monthly benefit? [ ]Yes
[ ]No [ ]Situation has not occurred
If “No,” what was the impact on the beneficiary(ies)?:

Information from SSA reviewer:
36. Did the payee break any SSA rules regarding fee charging? (A FFS payee is permitted to collect the lesser
of 10% of monthly benefit or the current allowable amount less any compensation for payee services from
another source.)
[ ]Yes
[ ]No
If “Yes,” explain:

Part 8 – Determining Beneficiary Needs
Information from payee:
37. How often and under what circumstances do you see/speak to the beneficiaries to keep informed of their
needs? (For children in foster care, how often do social workers visit the children to keep informed of their
needs and welfare?)

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38. Do beneficiaries have ready access to you?

[ ]Yes [ ]No

If “No,” how do you ensure beneficiary needs are met?

39. Do you actively help beneficiaries in other ways (e.g., trying to negotiate the best deals from landlords,
grocers, and banks; shopping for bargains and sales; learning of needs; seeking medical help; finding
suitable housing; establishing a process for social workers to obtain necessary items/services for a foster
child; notifying adoptive parents that a child may be eligible for benefits)?
[ ] Yes
[ ] No
Explain answer:

40. If you serve institutionalized beneficiaries, do you set aside at least $30 per month for their personal needs?
[ ] Yes
[ ] No
If “No,” explain:

41. If you serve non-institutionalized beneficiaries do you set aside any money for discretionary spending
(exclude charges for care and maintenance)? [ ] Yes [ ] No
Explain answer:

42. If the beneficiaries are children in foster care, do you set aside some of the children’s own funds or provide
funds for children when they attain age 18 to help them transition into adulthood?
[ ] Yes

[ ]No

Explain answer:

43. Do any beneficiaries in the sample have unmet needs?

[ ] Yes [ ] No

If “Yes,” explain:

Part 9 – Use of Benefits
Information from payee:
44. Do any beneficiaries live in a facility(ies) or housing that you, a relative of yours, or your organization
own or operate?
[ ] Yes
[ ] No
If “Yes,” explain the arrangement:

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45. How do you establish and/or budget for current maintenance costs?

46. Do you save for beneficiaries’ future needs?

[ ]Yes

[ ]No

If “No,” explain:

47. Do you ever disburse cash, including negotiable instruments such as checks, debit cards, gift cards and
money orders, directly to a beneficiary other than small sums for discretionary spending or personal needs or
disburse cash to a third party? [ ]Yes
[ ]No
If “Yes,” for each beneficiary list:
Name

SSN

Amount

Frequency
(e.g., weekly)

Method
(e.g, cash, check)

Reason for
Disbursement

48. a. Did you receive any past-due (retroactive) benefits which were used to pay a past debt owed to you?
[ ]Yes

[ ]No (go to 49)

b. If “Yes,” was SSA approval obtained?

[ ]Yes

[ ]No

If “No,” explain:

Information from SSA:
49. a. Is the payee a “conduit” payee (a payee who turns over all or most money to a beneficiary or someone
else to decide how to use) for any beneficiary? [ ]Yes
[ ]No (go to 50)
b. If “Yes,” explain how the payee is mismanaging disbursements:

c. List:
Beneficiary Name

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SSN

Action Required to Resolve

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50. Does the payee receive and disburse benefits in the best interests of the beneficiaries?
[ ] Yes
[ ] No
If “No,” explain:

Part 10 – Reporting Events
Information from payee:
51. What process do you use to report changes (e.g., change of address, income, resources, reports of death
to 800# or servicing FO) that affect Social Security or SSI benefits?

52. What process do you use to report when a beneficiary is no longer in your care (e.g., adoption of a child in
foster care) or you have lost contact with a beneficiary and to report changes in a beneficiary’s competency
(appointment of a guardian)/capability?

53. How do you handle conserved funds when a beneficiary is transferred or discharged from your care (funds
must be returned to SSA) or dies (conserved funds of deceased beneficiaries must be turned over to estate)?

54. What process do you have in place to insure the completion of annual accounting reports, work and/or
medical continuing disability reviews, and SSI redeterminations?

55. Do you negotiate or deposit the Social Security or SSI checks of any beneficiaries for whom you are not
[ ]Yes [ ]No
the representative payee in an operating account?
If “Yes,” list the names and SSNs of these beneficiaries:

Information from SSA Reviewer
56. Does the payee submit accurate and timely annual accounting reports (See the answers to questions 13
and 54.)?
[ ]Yes [ ]No

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If “No,” explain the plan for remedying this problem and the plan for the payee to submit overdue
reports:

57. Does the payee submit other reports timely? [ ]Yes

[ ]No

If “No,” explain and include plans for correcting reporting problems: (Exclude annual accounting
reports because they are covered in question 56. Include your resolutions to any issues raised by
answers to questions 15, 19, 20, and 55. Provide the names and SSNs of beneficiaries named in
question 55 to the servicing FO if development of assignment of benefit and capability issues is
necessary.)

Part 11 – Payee’s Banking Procedures (See answer to question 17.)
Information from payee:
58. Do you use direct deposit for all beneficiaries?

[ ] Yes [ ] No

If “No,” explain why not, and how paper checks are safeguarded until negotiated:

59. Do you keep beneficiary funds in a bank account(s)? [ ] Yes [ ] No
If “Yes,” describe the type of account(s) used and how you use the accounts to help manage the
beneficiaries’ funds (e.g., benefits received in a collective checking account via direct deposit, checks for
living expenses written from collective account, conserved funds held in individual savings accounts) and
to pay beneficiary bills:

If “No,” explain how you manage beneficiary funds and pay beneficiary bills:

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Part 12 – Collective Accounts (Complete this Part if the payee reported a collective account in question
59. Otherwise go to Part 13, if the payee reported a checking and/or savings account in question 59; or go to
Part 14, if the payee reported no accounts in question 59.)
Information from payee:
60. Provide the following information about the collective account:
Bank Name & Address:
Type of Account (circle applicable type) : Savings/Checking
Account #:
Title of Account (format) :
61. Does the bank charge any fees? [ ]Yes [ ] No (go to question 63)
If “Yes,” how much are the fees and what are they for?

62. Are the fees charged to the beneficiaries? [ ] Yes [ ] No
If “Yes,” explain the fee-charging method:

Information from SSA reviewer:
63. Is the collective account correctly titled?

[ ] Yes

[ ] No

If “No,” explain:
64. Is the collective account separate from payee’s operating account? [ ] Yes

[ ] No

65. Is interest prorated and credited to beneficiaries on the basis of their share of account funds?
[ ] Yes [ ] No [ ] Account not interest-bearing
If “No,” explain:

66. Are records showing each beneficiary’s share of account clear and up to date? [ ] Yes

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[ ] No

67. Does the payee correctly document credits and debits of each beneficiary? [ ] Yes

[ ] No

68. Are there any problems with the account (other than any titling problem addressed in questions 63)?
[ ]Yes

[ ]No

If “Yes,” explain:

69. Does the collective account meet SSA requirements for re-approval? [ ] Yes

[ ] No

If “Yes,” update the RPPR screen.
If “No,” update the RPPR screen and explain:

Part 13 – Checking and Savings Accounts (If the payee reported a checking and/or savings account
in question 59, complete this Part. If the payee reported more than one checking and/or savings account in
question 59, record information about the first checking or savings account in questions 70 through 73 and
use the Remarks/Observations section to record information required in questions 70 through 73 for the
additional account(s) .
Information from payee:
70. Provide the following information about the account(s):
Bank Name & Address:
Type of Account (circle applicable type) : Savings/Checking
Title of Account (format) :
List Beneficiary Names (in the sample) and Account #’s (Complete this item when account is not the
direct deposit account on MBR/SSR):

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71. Does the account earn interest and are beneficiaries credited with the interest? [ ] Yes

[ ] No

If “Yes,” explain how and when interest is credited and how reflected in the payee’s records:

If “No,” why not?

72. Does the bank charge any fees? [ ] Yes [ ] No
If “Yes,” what are the fees for, how much are they, and how are they charged to beneficiaries?

Information from SSA reviewer:
73. Are accounts (other than any collective account addressed in question 63) holding beneficiary funds
properly titled? [ ] Yes [ ] No
If “No,” explain and describe the scope of the problem:

74. Are there any problems with the account(s) (other than any titling problem addressed in question 73 and
[ ] No
other than any collective account problems addressed in questions 63 and 68)? [ ] Yes
If “Yes,” explain:

Part 14 – Dedicated Accounts
Information from payee:
75. Were you required to establish a “dedicated” account for a minor child/individual receiving SSI benefits?
[ ]Yes
[ ] No (go to Part 15)
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76. Do you still maintain funds in a dedicated account?

[ ] Yes

[ ] 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.
If “No,” explain how funds were used and go to question 78:

77. Did you make expenditures from this account during the period of review?

[ ] Yes

[ ] No

If “Yes,” explain what expenditures were for:

Information from SSA reviewer:
78. Were dedicated accounts managed properly (any expenditures were for medical treatment, education, job
skills training, other expenses related to the beneficiary’s impairment)
[ ] Yes
[ ] No
If “No,” explain:

Part 15 – Other Financial Instruments
Information from Payee:
79. Do you hold any conserved funds of beneficiaries in the sample in another account (e.g.,burial account,
money market account) not previously mentioned or by another method (e.g.,mutual funds, property)?
[ ] Yes

[ ] No

If “Yes,” describe and provide evidence of the financial instrument or property:

Part 16 – Recordkeeping
Information from payee:
80. Describe your recordkeeping system (e.g., paper ledgers, automated ledgers, patient accounts maintained on
site, check ledgers) . Include in your description:

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Any internal controls in place (e.g., periodic record reconciliations, independent audits, internal audits,
countersignature requirements, separation of employee duties, restricting access to beneficiary accounts,
safe or locked cabinets for checks stock, etc.) for monitoring and safeguarding individual beneficiary
funds;
Your process for paying beneficiary bills and the supporting documentation you maintain; and
Your procedures for providing beneficiaries with discretionary spending money or a personal needs
allowance and overseeing these disbursements.

81. Have you filed a claim with an insurer due to employee dishonesty, or fired, or asked any employees to
resign due to bookkeeping irregularities within the past 24 months? [ ] Yes
[ ] No
If “Yes,” explain:

Information from SSA reviewer:
82. Are the financial records (ledgers, receipts/invoices, bank statements, cancelled checks) retrievable and
orderly?
[ ] Yes
[ ] No
If “No,” explain:

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83. Do ledgers correctly and clearly identify both receipts of benefits and expenditures; and do checking account
registers, cancelled checks, and receipts/invoices correctly and clearly identify expenditures?
[ ] Yes

[ ] No

If “No,” explain:

84. Are records accurate (all funds accounted for, ledger balance for individual beneficiaries equals the balance
shown on the corresponding bank statements) and up-to-date (benefit payments and expenditures posted to
ledgers and checking account registers timely) ? [ ] Yes
[ ] No
If “No,” explain:

85. Are you able to follow the electronic or paper trail that supports the receipt and disbursement of beneficiary
funds? [ ] Yes
[ ] No
If “No,” explain:

86. Did the payee make any expensive or unusual purchases for beneficiaries in the sample?
[ ] Yes

[ ]No

If “Yes,” list (so you can complete the Note to Interviewers on the SSA-639.):
Beneficiary Name

Item/Service

Purchase Date

Payee’s Documentation

87. For SSI beneficiaries in the sample, does any SSI beneficiary’s ledger reflect a balance/combined balance
over $2,000 ($3,000 for a couple) as of the first moment of any month during the entire review period? (See
the answer to question 12 and review ledger balances for the period of review. Substitute bank records if
payee does not keep a ledger or ledgers are inaccurate.)
[ ] Yes [ ] No

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If “Yes,” list::
Name

SSN

Resource
Description

Dates Ineligible

88. Did the payee conserve unspent funds appropriately?

Beginning and Ending
Balance

[ ] Yes [ ] No

If “No,” explain: (Recommend placing conserved funds regardless of amount in interest-bearing
accounts.):

Part 17 – Other
Information from payee:
89. Do you need any help to carry out payee duties from SSA or do you need SSA’s help to resolve any
problems?
[ ] Yes [ ]No
If “Yes,” explain:

Information from SSA reviewer:
90. Does SSA need to provide training to the payee in any area?

[ ] Yes [ ] No

If “Yes,” explain what is needed and how it will be accomplished:

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91. If you answered question 19 or question 20 “Yes,” has the payee corrected the problems noted?
[ ] Yes
[ ] No
If “No,” explain:

Part 18 – Beneficiary Interview Sample
Information from SSA reviewer:
92. Tell the payee the names of the beneficiaries in the sample that you plan to interview (include any
beneficiaries listed in question 86) and list their names below:

Information from payee:
93. Do any of these beneficiaries have difficulty responding to questions?

[ ]Yes

[ ]No

If “Yes,” what are their names and what is the name of each one’s custodian/caregiver, job title (e.g.,
social worker, nurse, home health aid) or concerned relative, and phone number:
Beneficiary

Contact Name

Title/Relation

Part 19 – Remarks/Observations (for SSA use)

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Phone

Part 20 – Recommendations and Action Items (for SSA use)
Payee:

SSA:

Date interview guide and closeout letter to FO/RO:

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Privacy Act Statement

See revised
Privacy Act
Statment below
Sections 205(j) and 1631(a) of the Social Security Act allows 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. The information you furnish on this form is
voluntary. 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.
We rarely use the information you supply for any purpose other than for monitoring the performance
of you as a 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.

Paperwork Reduction Act Statement
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 2 hours to read the instructions, gather the facts, and answer the
questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
To find the nearest office, call 1-800-772-1213 (TTY 1-800-325-0778). Send only comments on our
time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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