Ssa-623-f6

Social Security Administration
Representative Payee Report
Please complete the enclosed Representative Payee Report and return it to us. We must ask you
to complete this report when you receive Social Security or Supplemental Security Income (SSI)
payments for another person. We use the facts you give us to make surethat you are using the
payments to meet the person's needs.
We changed two questions on the report this year. Our intent in asking the new questions (items 5.C
and 7. on the form) is to make sure that the beneficiary's immediate needs are being met, and to
record the amount of benefits you may have saved for the beneficiary.
a

What You Need To Do

Some Definitions

Please read the instructions before you complete
the report. This is important because not all
questions are self-explanatory. Then, complete
your report and send it t o us in the
enclosed envelope within 10 days from the day
you received it. If you do not return i t promptly,
we may stop sending checks to you.

Benefits-The
you receive.

Social Security and SSI money

Beneficiary-The person for whom you receive
Social Security or SSI benefits.
Custodian-The person or institution the
beneficiary lives with.

General Instructions
To help us process your report, please follow
these instructions.

1. Use black ink or a #2 pencil.

Payee--You. The person who receives Social
Security or SSI benefits for someone else.
Report Period-The months for which you
must account on this report. The report period
is shown at the top of the form, near your name.

2. Keep your numbers and "X's" inside the boxes.

3. Try to make your numbers look like these:

4. Do not use dollar signs.
5. Enter money amounts in dollars only. Do not
show cents. Show $540;30 like this:'
DOLLAR AMOUNT

6. Continue to keep records of how you use the
Social Security or SSI money, but do not
submit receipts, cancelled checks or any other
records with this report. If we need to verify
the facts you give us, we will contact you.

FORM SSA-623-F6(7-91)
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How To Fill Out The Form

3A.-Child's Marriage

The numbers below match the numbered
questions on the report.

Place an T in the "YES" box if the child
married. Otherwise, place an “X" in the "NO"
box.

l-Custody Of The Beneficiary

$.B.-Child's Spouse

Place an "X'' in the "YES" box in item 1if:

If you answered "YES" in 3.A., you must
complete this item. Place an "X" in the "YES"
box if the child's spouse receives Social Security
benefits. Otherwise, place an "X" in the "NO"
box.

the beneficiary lived with you for some but
not all months in the report period, or
the beneficiary lived in an institution for
some but not all months in the report
period, or

3.C.-Date Child Married

the beneficiary lived alone for some but not
all months in the report period, or

If you answered "YES" in 3.A., you must
complete this item. Show the month and year of
the child's marriage in numbers. For example, if
the child married in May 1990, show the date
as:

there was a change in custody such as the
beneficiary moved from one institution to
another.
Place an "X" in the "NO" box in item 1if:
the beneficiary lived with the same person
during the entire report period, or

4-Turning Over Payments To Another
Person

the beneficiary lived in the same institution
during the entire report period, or

Place an "X" in the "YES" box if you gave the full
amount of benefits to:

the beneficiary lived alone during the entire
report period.

Another person who decided how to use the
money.

Do not consider short visits (vacations,
weekend or holiday visits) with another
person when you answer this question.

The beneficiary who decided how to use the
money.

2-Felony Question

Place an "X" in the "NO" box if you:

You must complete this item. Place an "X" in the
"Yes" box if you were convicted of a crime
considered to be a felony during the report
period shown at the top of the form. Otherwise,
place an "X" in the "NO" box.

Decided how to use the money.
Told an institution or nursing home how to
use the money.

5-How You Used The Benefits

3-Child's Marriage

When you complete this item, show total dollar
amounts for the entire 12-month report period.

You must complete this item only if you receive
Social Security benefits for:

5A-Food and Shelter

a child under 18. or
a beneficiary disabled before 22 who receives
benefits on a parent's Social Security record.

of benefits you spent for
Show the total
food and shelter for the beneficiary during the
entire 12-month report period. If the beneficiary
resides in an institution or a nursing home and
you Pay monthly maintermnee charges, multiply
the monthly charge by 12.

Otherwise, leave this item blank.
A child's marriage can cause the child's benefits
to stop. If you do not complete this item for the
child, we may stop the child's benefits.

FORM SSA-623-F6(7-91)

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5.B.-Personal Needs

&Type And Title of -"Other"Account

In this item include the amount of Social
Security benefits you spent on clothing, medical
and dental care, education, and recreational
items like toys, movies, cameras, radios, and
musical instruments. Also include other
personal items like stationery, grooming aids,
and candy. Do not include the money you
spent on food and shelter.

If you answered "OTHER" in 7.A. or 7.B., you
must complete this item.

5.C.-Unused Benefits
Show the total amount of benefits you saved for
the beneficiary during this report period.
Show zeroes or "none" if you spent all the
benefits.

6-Total Savings

8.A.-If you answered "OTHER" in 7.A., describe
the way you saved Social Security benefits. For
example, U.S. Savings Bonds, cash, etc.
8.B.-If you answered "OTHER" in 7.B., show
the title of the account. If you do not put the
savings in an account, show "None."

You must sign your name in this block. If you
please have two witnesses
sign by mark (T),
sign their names and show the date.

10-Relationship To The Beneficiary

Complete this item if you have saved benefits
from any report period. Only include money
received as Social Security or SSI benefits.
Show the total amount of benefits you have
saved. If you do not have any saved benefits,
show zeroes or "None" and go to item 9.

Show your relationship to the beneficiary. For
example, "parent, brother, friend, legal guardian
or none." If you represent a bank, institution or
agency, show your title.

7-Type And Title Of Account

Your Job As A Representative Payee

If you showed any amount in item 6, you must
complete this item.

As a payee, you must use the Social Security and
SSI benefits you receive for the care and wellbeing of the beneficiary. You need to be aware of
what the beneficiary needs so that you can
decide how best to use the money.

7.A.-Type of Account
Place an 'X" in the box.that describes the type of
account in which you saved benefits. Place a n
'X" in the "OTHER" box if:
you save in a different type of account, or
you do not put savings in any type of account.
You may mark more than one box.

7.B.-Account Title
Place an 'X" in the box that describes the title
(name) of the account(s) you showed in 7.A.
Place an 'X"in the "OTHER" box if:
the account title is not shown, or
you do not put the savings in any type of
account.

Benefits should be saved in an account
which shows that the money belongs to the
beneficiary. If you are not sure whether
the account you established does this, you
should check with your bank and change
the account title if necessary.
FORM SSA-623-F6(7-91)

You must also tell us about any changes which
may affect the checks you receive. You need to
tell us if:
The beneficiary moves (especially if he or she
enters or leaves a hospital or institution),
marries, goes to work, dies or is adopted.
You are no longer responsible for the
beneficiary.
The beneficiary no longer needs a payee.

The Privacy And Paperwork Reduction
Acts
We are required by sections 2050') and 1631(a)of
the Social Security Act to ask you to complete
this report. Also, under section 202(a) of the Act,
we need to know the information in item 3 for
beneficiaries who receive child's benefits,
because a marriage can cause a child's payments
to stop. Although completing the report is
voluntary, the law states that as a
representative payee, you have a responsibility
to do so. If you do not complete and return this
report to us, we may not be able to continue
sending the beneficiary's payments to you.
Sometimes the law requires us to give out the
facts on this form 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 audits
needed to administer or improve our
representative payee program.
We may also use the information you give us
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.
These and other reasons why information about
you may be used or given out are explained in
the Federal Register. If you want to learn
more about this, contact any Social Security
office.

FORM SSA-623-F6(7-91)

Time It Takes To Complete This Form
We estimate that it will take you about 10
minutes to complete this form. This includes the
time it will take to read the instructions, gather
the necessary facts and fill out the form. If you
have comments or suggestions on this estimate,
or on any other aspect of this form, write to the
Social Security Administration, ATTN: Reports
Clearance Officer, 1-A-21Operations Bldg.,
Baltimore, MD 21235, and to the Office of
Management and Budget, Paperwork Reduction
Project (0960-0068),Washington, DC 20503. Do
not send completed forms or information
concerning your claim to these offices.

If You Have Any Questions
If you have any questions, you should call, write
or visit your local Social Security office. Almost
all questions can be answered by phone. If you
visit an office, please bring this report with you.
This will help us answer your questions.

Representative Payee Report

FORM APPROVED

om NO.09604068

This report is about the benefits you received during the 12-month report period shown above. Please
read the enclosed instructions before completing this form. It will help you answer each question.

1

YES

Has the beneficiary's custodian changed during the report period shown above?
Please refer to the instructions on page 2 before you answer this question.

n

NO

I

n

U I U

During the report period shown above, were you convicted of a crime considered

2* to be a felony? If YES, please explain in "Remarks" on the back of this form.

Answer this question only if you received Social Security benefits for a child under

3*age 18 or disabled before age 22 who receives benefits on a parent's Social Security
record. Otherwise go to item 4.
A, Has the child married?

B,
C,

t

If YES, is the child's husband or wife receiving Social Security benefits?
Enter the month and year of the child's marriage.

t

4,

Did you turn over the full amount of the benefits to another person during the
report period (for example, to the beneficiary's custodian or to the beneficiary)?
If you answer YES, please explain in "Remarks" on the back of this form.

5,

During the report period shown above, you received benefits on behalf of another person.

DOLLAR AMOUNT
(NO CENTS)

How much of these benefits did you spend on food and shelter for the beneficiary
t
during the entire report period?

B,

How much of these benefits did you spend on all other things such as clothing,
education, recreation and personal items for the beneficiary during the entire
report period?
t
How much, if any, of the total benefits you received during this report period did
t
you save for the beneficiary? If none, show zeroes or "None."

6,
7,

Show the total dollar amount of benefits, if any, you have saved for the beneficiary. Be sure to
include benefits saved from earlier report periods. If none, show zeroes or "None."
If you showed a n amount in 6. above, place an " X in the boxes below to show how you are saving the
remaining benefits. If you have more than one account, you may mark more than one box in each section.

I

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A. TYPE OF ACCOUNT
Checking
Account

Savings
Account

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FORM SSA-623-F6(7-91)
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Collective Savings1
Patients' F u n d

Other

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B. TITLE OR OWNERSHIP
Beneficiary's Name
by Your Name

Your Name for
Beneficiary's Name

Other

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F

8.A.
B

e

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If you answered "OTHER in 7.A. on the front
page, show the type of account or investment
in which the benefits are saved.

TYPE OF

TITLE OF ACCOUNT
If you answered "OTHER" in 7.B.on the front
page, show the title of the account in which
t
the benefits are saved.

REMARKS

I CERTIFY THAT THE INFORMATION I HAVE GIVEN ON THIS FORM IS TRUE. (A PERSON WHO
CONCEALS OR FAILS TO TELL SSA ABOUT EVENTS ASKED ABOUT ON THIS FORM WITH THE
INTENT TO FRAUDULENTLY RECEIVE BENEFITS MAY BE FINED. IMPRISONED OR BOTH.)
YOUR SIGNATURE
(If signed by mark (X), two witnesses must sign below)

RELATIONSHIP TO BENEFICIARY OR TITLE

DAYTIME TELEPHONE NUMBER(S)
(Include area code)

WITNESS SIGNATURESARE REQUIRED ONLY IF THE PAYEE'S SIGNATURE ABOVE
HAS BEEN SIGNED BY MARK (X).
SIGNATURE OF WITNESS

DATE

SIGNATURE OF WITNESS

DATE

FORM SSA-623-F6(7-91)