Form SSA-624 Representative Payee Evaluation Report

Form Approved
OMB No. 0960-0069

SOCIAL SECURITY ADMINISTRATION

REPRESENTATIVE PAYEE EVALUA-riON REPORT

TP

TYA
BENEFICIARY'S NAME

SOCIAL SECURITY NUMBER

PAYEE'S NAME

REPORT PERIOD
From:
To:

PAYEE'S ADDRESS

PHONE NUMBER (Include area cod

ZIP CODE

CITY AND STATE

)

(

PART I
1.

INFORMATION FROM PAYEE

GUARDIANSHIP STATUS
Is legal guardianship now in
effect?

~

GUARDIAN'S NAME

DVES

DNO

If yes, show guardian's name and address below (if other than payee).
GUARDIAN'S ADDRESS

2. CUSTODY

CJ VES

(a) Did the beneficiary live alone or with someone
other than the payee?

~ If yes, answer 2(b).

CJ NO
If no, skip to item 4.

(b) Show below where the beneficiary lived. Show the relationship of the custodian to the beneficiary, the dates of residence and the
reason for any change in custody.
RELATION­
SHIP

ADDRESS

NAME

DATES OF
RESIDENCE

3. DEMONSTRAnON OF CONCERN
(a) How did the payee learn of the beneficiary's needs?

(b) Did the payee maintain contact with the beneficiary? If yes, show type
of contact (visits, phone, letters) and frequency.
If no, explain.
(c) Did the payee provide the beneficiary with funds for personal spending?
If yes, show to whom the funds were given (e.g., directly to the
beneficiary, the custOdian).
If no, show why not.

DVES

CJ NO

DVES

DNO

DVES

DNO

~

~

4. USE OF BENEFITS
(a) Did the payee turn over the checks or the full amount of the checks to
another party?
If yes, show to whom the funds were given (e.g., the beneficiary, the
custodian).
(b) Amount used for beneficiary's care and maintenance. If paid to another
party, show to whom.
Form SSA-624-FS (9-2004) ef (12-2006)

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Destroy Prior Editions

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~

NAME
AMOUNT $
NAME

REASON
FOR CHANGE

PART I (continued)

4.
(c_.l

~

AMOUNT
$

(d) Amount used for beneficiary's personal expenditures.
If less than $360, explain in remarks.

~

AMOUNT
$

(e) Amount used for other than items (b) through (d) above.
(Exclude savings.) Explain in remarks.

,~

AMOUNT
$

(f) Total amount of benefits used.

~

TOTAL AMOUNT
$

(g) Did the payee record expenditures (receipts, cancelled checks, etc.)?

~

(c) Amount used for beneficiary's clothing.

DYES

DNO

5. CONSERVED FUNDS

,

(a) Total amount of conserved funds.
Subtract item 4(f) from TVA and add conserved funds from prior years.
(b) How are conserved funds held?

o
o

o
o

CASH
CHECKING ACCOUNT

~

AMOUNT
$

o

U.S. SAVINGS BONDS

Enter an amount or zero
in the above field

OTHER (Explain)

SAVINGS ACCOUNT

(c) HOW ARE CONSERVED FUNDS TITLED?

TITLE OR
O\NNERSHIP

TYPE OF
HOLDING

NAME AND ADDRESS
OF BANK

(d) Are the funds mingled with funds of another person(s)?

DYES

ACCOUNT
NUMBER

(e) Are funds clearly recorded as belonging to the
beneficiary?

DNO

If yes, answer (e).

DYES

DNO

DYES

DNO

6. OTHER INCOME
(a) Did the benefiCiary have other income which
affects the entitlement to or use of Social Security
benefits?
(b) Type Of Other Income

o
o

~

WORKMEN'S COMPENSATION
OTHER (Explain)

~

(c) Is there a payee for other income?

If yes, answer (b) and (c).

o
o

VA BENEFITS
PUBLIC ASSISTANCE (Explain)

DYES

DNO

If yes, show name and address of payee below.

NAME OF PAYEE

ADDRESS OF PAYEE

7. OTHER INFORMATION
Has the payee ever been convicted of a crime considered to be
a felony?

~

DYES

DNO

If yes, explain in remarks.

8. REMARKS

I declare under penalty of perjury that I have examined all the Information on this form, and on any accompanying statements or forms,
and It is true and correct to the best of my knowledge.
DATE

SIGNATURE
(
;­

Form SSA·624·F5 (9-2004) ef (12.2006)

2.

PART II

INFORMATION FROM BENEFICIARY

1. ALL CUSTODY SITUATIONS
(a) Is the beneficiary aware of entitlement to Social Security
benefits?

DYES

(b) Did the beneficiary participate in decisions on
expenditures?

DNO

DYES

(c) Did the beneficiary receive funds for personal spending?

DYES

(d) Were any large purchases made for the beneficiary?

DNO

DYES

(e) Does the beneficiary have any unmet needs?

DYES

DNO

~

If yes, explain.

(g) Did the beneficiary live alone?

DYES

DNO

If yes, answer 2. below.

2.

DNO

EXPLANATION

(f) Did the beneficiary live with someone other than the payee?

DYES

DNO

DNO

If yes, answer 2. and 3. below.

BENEFICIARY NOT IN PAYEE'S CUSTODY
(a) Did the payee maintain contact with the beneficiary?

DYES

DNO

If yes, show type of contact (visit, phone, letters) and frequency. If no, explain.
(b) Did anyone other than the payee demonstrate concern for the beneficiary?

DYES

DNO

If yes, show who and type and frequency of contacts.

3.

BENEFICIARY LIVED ALONE
(a) Was the benefiCiary responsible for his/her maintenance expenses?
(Rent, utilities)

DYES

4.

DNO

(b) Did the beneficiary purchase his/her food and clothing?

DYES

DNO

DYES

DNO

OTHER INFORMATION
Have any suspension or termination events occurred (e.g., marriage of child ~
beneficiary)?

5. REMARKS

Form SSA-624-F5 (9-2004) ef (12-2006)

3.

(If yes, explain in remarks)

PART III

INFORMATION FROM CUSTODIAN

PHONE (Include area code)

ADDRESS

CUSTODIAN'S NAME

(

1.

)

­

PAYEE AND CUSTODIAN ARE NOT THE SAME PERSON OR ORGANIZATION
(a) Did the beneficiary live with the custodian during the entire report
period?

~

DYES
If no, show other custodians if known.

DNO

(b) Who would the custodian notify in cases of emergency?

(c) Was a charge made for care and maintenance of the
beneficiary?
If yes, show the amount paid by the payee.

DYES

~

(d) Did the payee demonstrate personal concern for the
beneficiary?

~

PROVIDES CLOTHING

FREQUENCY OF VISITS

DYES

DNO

If yes, explain below.
OTHER (Specify)
DYES

DNO

DYES

~

~

(g) Are the beneficiary's funds mingled with funds of other persons?

Amount $
DYES

DYES

DNO

If yes, were the purchases approved by SSA?

~

DNO

DYES

3. REMARKS

EVALUATION AND ACTION TAKEN

IOfFICE

SIGNATURE AND TITLE

Form SSA-624-F5 (9-2004) ef (12-2006)

DNO

If yes, answer (g).

~

ALL CUSTODIANS
Were any group purchases made?

PART IV

DNO

If yes, are the funds clearly deSignated as the beneficiary's?

DNO

DYES

DYES

DNO

(f) Does the custodian hold and control the beneficiary's
personal use funds?

2.

Amount $

GIFTS

(e) Did the payee contribute money for the beneficiary's
personal use? If yes, show the amount contributed by
the payee.

DYES

DNO

4.

DNO

THE PRIVACY AND PAPERWORK REDUCTION ACTS

Sections 2050) and 1631(a) of the Social Security Act allow us to collect the information
on this report. The information gathered on this report enables the Social Security
Administration to determine continued payee suitability and if the beneficiary's needs are
being met. If you do not provide this information, we may not be able to continue to
send the beneficiary's payments to the representative payee.

revised
The law sometimes requires us to give See
out the
facts on this form without your consent.
The information must be released to another
person
Privacy Act or government agency if Federal law
requires the information for research and
audits in order
to administer or improve our
Statement
below.
representative payment program.
We may also use the information you give us when we match records by computer.
Matching programs compare our records with those of Federal, State, or local
government agencies. Many agencies use matching programs to find or prove that a
person qualified 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 us 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.
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 30 minutes to read the instructions, gather the facts,
and answer the questions related to representative payment. SEND OR BRING THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The
office is listed under U. S. Government agencies in your telephone directory or you
may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). 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·624-F5 (9-2004) ef (12-2006)

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(j)(3) and 1631(a)(2)(c) of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide to determine your suitability to
continue being a representative payee and to determine if the beneficiary’s current needs are
being met.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may cause us to terminate you as a representative payee.
We rarely use the information you supply us for any purpose other than to make a determination
regarding your suitability as representative payee and the beneficiary’s current needs. We may
disclose information to another person or to another agency in accordance with approved routine
uses, which include but are not limited to the following:
1. To enable a third party or agency to assist us in establishing rights to Social Security
benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
We also may use the information you give us in computer matching programs. Matching
programs compare our records with records kept by other Federal, State and local government
agencies. We use the information from these programs to establish or verify a person’s
eligibility for federally funded or administered benefit programs and for repayment of incorrect
payments or delinquent debts under these programs.
A complete list of routine uses of the information you provided us is available in our Systems of
Records Notices entitled, Claims Folder System, 60-0089 and Master Representative Payee File,
60-0222. These notices, additional information regarding this form, and information regarding
our programs and systems, are available online at www.socialsecurity.gov or at your local Social
Security office.