Form SSA-623 Representative Payee Report (Adult)

Social Security Administration
Representative Payee Report
Why You
Received
This Form

We must regularly review how representative payees used the benefits they
received on behalf of the Social Security and/or Supplemental Security Income (SSI)
beneficiaries. We do this to ensure the benefits are used properly. When you were
appointed representative payee, you were informed of the duties and responsibilities
of a representative payee, including keeping records and reporting on the use of
benefits.

What You Need
To Do

You must report to SSA on your use of benefits if you received any Social Security
and/or SSI payments during the 12 month period shown on the enclosed form. You
must do this if you wish to continue receiving benefits on behalf of another person.
You should use the records you have saved to answer the questions on the enclosed
form.
You may submit this form online via www.socialsecurity.gov/payee.
Please follow the instructions for Internet Payee Accounting Report. If
you complete the form online, you will be able to print a receipt and a
copy of your report. If you report online, you should have all your
records and the enclosed form handy to help you answer the questions.
You should not send in a paper form if you complete the online version.
Any records you have saved such as bank statements, cancelled checks, receipts
for rent, etc., should be kept for two years from the time you file your report with
SSA. You should not send in any of these records with your report form. If we
have any questions or require proof, we will contact you.

General
Instructions If
You Complete
and Return The
Enclosed Form

Please read these instructions before you complete the enclosed report form or submit
your report online. You should either complete and return the report form, or submit
the online report, within 30 days.
To help us process your report, please follow these instructions:
1.
2.
3.
4.

Use black ink.
Keep your numbers and “X’s” inside the boxes.
Do not use dollar signs.
Show money amounts in dollars only. Do not show cents.
For example, show $1,540.70 like this:
DOLLAR AMOUNT

,.

5. Use the REMARKS section on the back of the form to provide additional
information as requested.
6. Review the payee mailing address and correct if necessary. If you change the
payee mailing address to a P.O. Box, show the payee’s actual physical address in
REMARKS.
7. Be sure you, the representative payee, sign the form.

FORM SSA-623-OCR-SM (10-2008)

1

Continued on the Reverse

Some
Definitions
To Help You

Benefits – The Social Security and/or SSI money that you receive.
Payee – You. The person (or organization) who receives Social Security and/or SSI
benefits for someone else.
Beneficiary – The person for whom you receive Social Security and/or SSI benefits.
Legal Guardian – The person or organization appointed by a State court to
manage the affairs of a beneficiary.
Report Period – The 12-month period shown on the report for which you must
account for the benefits you received.
Total Accountable Amount – The amount of benefits paid to you during the
report period plus any amount you reported as saved on last year’s report.

HOW TO FILL OUT THE FORM
QUESTION 1 –
Payee Felony
Convictions

Place an “X” in the “YES” box if during the report period, you (the
payee) were convicted of a crime considered to be a felony and explain
the type of crime under REMARKS. Otherwise, place an “X” in the
“NO” box.

QUESTION 2 –
Beneficiary
Custody
Changes

Place an “X” in the “YES” box if the beneficiary continued to live
alone, or with the same person, or in the same institution during the
entire report period. Place an “X” in the “NO” box if different people
or different institutions took care of the beneficiary during any part of
the report period. Explain the change and provide the
beneficiary’s current address under REMARKS.

QUESTION 3 –
Accounting
For Benefits

The total accountable amount includes the benefits you received
during the report period plus any benefits you reported as saved on
last year’s report.

A. Who Decided
How Benefits
Were Used?

Place an “X” in the “YES” box if you (the payee) decided how the
benefits were to be spent or saved. Place an “X” in the “NO” box if the
beneficiary or someone else decided how to use the money, and explain
under REMARKS.

B. Food and
Housing

Show the total amount of benefits spent for food and housing for the
beneficiary during the report period. If the beneficiary lives in an
institution or nursing home and you pay monthly charges, multiply the
monthly charge by 12 and show this total amount.

C. Personal
Items

Show the total amount of benefits spent on clothing, medical/dental
care, education, and recreational items like toys, movies, cameras,
radios, candy, stationary, grooming aids, etc. during the report period.
Note: If the beneficiary lives in an institution or other care facility, you
should spend at least $360 a year for the beneficiary’s personal needs.
If you spent less than $360, explain under REMARKS.

FORM SSA-623-OCR-SM (10-2008)

2

D. Unused
Benefits

Show the total amount of benefits you have saved for the beneficiary
at the end of the report period, including any interest earned. Show
zeroes if you did not save any of the benefits.

NOTE

For Social Security beneficiaries who are residing in an institution, use
REMARKS to provide the amount of benefits, if any, the state Medicaid
agency has determined are for the use of the community spouse and
other dependents, if applicable.

QUESTION 4 –
Savings
Information

Answer this question if you showed an amount in 3.D.

A. Type Of
Account

Place an “X” in the box which shows how you are saving the benefits.
Place an “X” in the “Other” box if your method of saving the benefits is
not listed.

B. Account
Title

Place an “X” in the box which most accurately describes the wording of
the account title you have on the beneficiary’s savings. Place an “X” in
the “Other” box if the account title is different or if you have not placed
the savings in any type of account. Note: A savings or checking account
title should always show that the money belongs to the beneficiary, but
the beneficiary should not have direct access to the funds.

QUESTION 5 –
Other Savings/
Account Titles

Answer this question only if you checked “OTHER” in 4.A. or 4.B.

A. Type Of
Account

Indicate whether the saved benefits are in cash, Treasury Bills, or some
other investment such as mutual funds. For mutual funds, be sure to
show the name of the fund in your response (e.g., “XYZ Growth” mutual
fund).

B. Title Of
Account

Show the title of the account if the savings are in an account or other
investment. Show “none” if the savings are not in an account or
investment.

6. Payee’s
Signature

Sign your name in this block. If you sign by mark (“X”), please have
two witnesses sign their names and show the date. If the payee is an
institution or agency, the form must be signed by an authorized person.

FORM SSA-623-OCR-SM (10-2008)

3

Your Responsibilities As
Representative Payee

The law sometimes requires us to give out
the facts on this form without your consent.
The information must be released to another
person or government agency if Federal law
requires the information for research and
audits in order to administer or improve our
representative payee program.

We appreciate your services as representative
payee. As payee, you must use the Social
Security and/or SSI benefits you receive for
the care and well being of the beneficiary. You
need to know the beneficiary’s needs so that
you can use the money properly.

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.
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.

In addition to reporting on the use of benefits,
you must report any changes which may
affect the beneficiary’s eligibility for benefits,
or the payment amount. You should report the
changes as soon as possible by calling SSA at
1-800-772-1213, or by calling or writing your
local SSA office. For example, you must tell us
if the beneficiary:
• dies,
• moves (especially if he/she enters or leaves a
hospital or other institution),
• marries,
• starts or stops working,
• is imprisoned,
• is adopted,
• no longer needs a payee, or
• you are no longer responsible for the
beneficiary.

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 15 minutes
to read the instructions, gather the necessary
facts, and answer the questions. You may
send comments on our time estimate above to:
SSA, 1338 Annex Building, Baltimore, MD
21235. Send only comments relating to
our time estimate to this address, not the
completed form.

If you are payee for a child receiving SSI
benefits, we may ask you for proof that the
child is receiving medical treatment for
his/her disabling condition. We may ask for
this information at the time we review the
child’s case. If we do ask for this information,
you must give it to us.

If You Have Any Questions

If you are no longer payee for the beneficiary,
you must return any Social Security funds
you have saved to SSA.

If you have any questions, please call us at
1-800-772-1213. We can answer most
questions over the phone. If you prefer to
visit one of our offices, please use the 800
number and we will give you the address and
telephone number of the office nearest you.
Please take this report with you if you visit an
office. You may also visit our website at
www.socialsecurity.gov.

The Privacy Act And Paperwork
Reduction Act Statements
We are required by sections 205(j) and
1631(a) of the Social Security Act to ask you
to complete this report. The information
you provide enables SSA to account for the
beneficiary’s payments, and ensures that
beneficiary needs are being met. If you do not
complete and return this report, we may not
be able to continue sending the beneficiary’s
payments to you.
FORM SSA-623-OCR-SM (10-2008)

See Revised PRA
and Privact Act
Statement
4

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:

Privacy Act Statement
Collection and Use of Personal Information

Sections 205(j) and 1631(a) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to ensure that payments are used for the
claimant’s needs.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from sending the claimant’s payments to you.
We rarely use the information you supply for any purpose other than for accounting purposes.
However, we may use the information for the administration of our programs including sharing
information:
1. 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);
and,
2. 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).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0222, entitled Master Representative
Payee File. Additional information about these and other system of records notices and our
programs is available from our Internet website at www.socialsecurity.gov or at your local Social
Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
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.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 (OMB) control number. We estimate that it will take about
15 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.