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 (07-2010)

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 (07-2010)

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REMARKS CONTINUED:

Interviewer's Name and Telephone Number

FORM SSA-639 (07-2010)

Date of Interview

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Privacy Act Statement

See revised
Privacy
Act
Sections 205(j) and 1631(a) of the Social Security Act allows us to collect
the information
requested on this
Statement
below.
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.

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. 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.

FORM SSA-639 (07-2010)

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