SSA-623: Representative Payee Report (Adult Beneficiaries)

6232

Representative Payee Report
Social Security Administration, P.O. Box 6230,Wilkes-Barre. PA 18767-9956
PAYEE'S NAME AND ADDRESS

FORI"l APPROVED
OI'vIBNO mlGO-OOG8

SOCIAL SECURITY NUMBER

REPORT PERIOD
FROM:

TO:
FP

BENEFICIARY

ID

TP

TAA

CF

If change at' address, check box and
enter new address on back of report.

D

BIC

CC

GS

PC

DOC

BSSN

PF

0

This report is about the benefits you received between
and
for the beneficiary,
. Please read the enclosed instructions before completing this fonn to help you answer each question.

1.

Were you (the payee) convicted of a crime considered to be a felony between
and
?
If 'YES, please explain in REMARKS on the back of this form.

2.
3.

Did the beneficiary continue to live alone, or with the same person, or in the same
institution from
to
? If NO, please explain and provide the
beneficiary's current address in REMARKS on the back of this form.
Benefits paid to you between
and
Benefits you reported as saved on last year's report.

=$
=$

Total Accountable Amount

=$

A•

Did you (the payee) decide how the $

..
..
..

was spent or saved?

If NO, please explain in REMARKS on the back of this form.

did you spend for the beneficiary'Sfoodand
and
?

B.

How much of the $
housing between

c.

How much of $
did you spend on other things for the
beneficiary such as clothing, education, medical and dental expenses,
recreation, or personal items between
and
?
I

of the $
did you save for the beneficiary as of
D. How much,?ifIfany,
none, show zeros.

4.

)lI-

YES

NO

D
D

D

YES

NO

D

D

DOLLAR AMOUNT
(NO CENTS)

I I I

I,I I I

I

I I I

I,I

I I

I

I

I

I

I I I, I

I

If you showed an amount in 3.D. above, place an "x" in the boxes below to show how you are saving
the benefits. If you have more than one account, you may mark more than one box in each section.

A. TYPE OF ACCOUNT
Savingsl
Checking
Account.

US. Savings
Bonds

D

D

Certificates
of Deposit

Collect.ive So vingsl Treasury
Bills
Bheokfnr; Account

D

«'OHMSSA-623-0CR-SM (02-2012)

D

D

B. TITLE OF ACCOUNT
Other

o

Beneficiary's Name
by Your Name

Your Name for
Honefici ary's Name

D

Other

D
Continued on the Reverse ----

.-~

FOR SSA USE ONLY

62328

A'1"l'D

UNDID

5.A.

B

rVIAHKD
UND2D

SIGD
O'I'UO

Answer this question only if you answered "OTHER" T'{PE OF ACCOUNT
in 4.A.on the front page. If you answered "OTHER"in
4.A. show the type of account.or investment in which
.....
the benefits are saved.

-

. Answer t.hisquestion only if you answered "OTHER"
TITLE OF ACCOUNT
in 4.B. on the front page. If yOLI answered "OTHER"in
• 4.B., show the title ofthe account.in which the benefits
....
are saved

--

REMARKS

NEW ADDRESS

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. I
understand
that anyone who knowingly gives a false or misleading statement about a material
fact in this information, or causes someone else to do so, commits a crime and may be sent to
'prison, or may face other penalties, or both.

PAYEE'S SIGNATURE

DATE

(If'signed by mark ("X"), two witnesses must sign below)

7.

DAY'IiIME TELEPHONE NUMBER(S)
(Include area code)

8.

6.
\VITNESS SIGNATURES
SIGNATURE OF WITNESS

ARE RE~IRED
ONLY IF THE PAYEE'S SIGNATURE
HAS BE ~'. SIGNED BY MARK rryr').
DATE

SIGNATURE OF' WITNESS
-FORM

SSA-623-0CR-SM

-

Area Code

DATE
(02·2012)

ABOVE