Form RI 38-115 RI 38-115 Representative Payee Survey

Form Approved:
OMB No. 3206-0208

Representative Payee
Survey
Show any address change next to your address below.

U.S. Office of Personnel Management
Retirement Surveys & Students Branch
1900 E Street, NW - Room 2309
Washington, DC 20415-3563

Date

Claim number

Survey period

Case name
Beneficiary's name

The purpose of this questionnaire is to ensure that Federal retirement benefit payments are being used in the best interests of the
beneficiary named above. The Office of Personnel Management (OPM) has approved you as payee because it has determined that the
beneficiary is not capable of handling his or her own affairs. We thank you for accepting this responsibility. Please read the instructions
below before completing this form and return the completed form in the enclosed envelope or in your own envelope to the address shown
above. Please return the completed form within 30 days after the date of this survey or we will have to stop paying these benefits.
We appreciate your cooperation.
Retirement Surveys and Students Branch
Instructions For Completing the Survey Form

We have provided information for each question. Please read this information before you respond. If you need another form or have
questions, please call (202) 606-0249. Individuals calling from outside the Washington DC area can call our Retirement Information
Office toll free at 1-888-767-6738. You can also write OPM at the address shown above.
1.

If you answer No, you must return all payments received after the death of the beneficiary to the U.S. Department of the Treasury.

2.

If you answer Yes, please complete the entire survey.

3.

If the beneficiary does not live with you, we need to know where and with whom he or she is living.

4.

If you are not receiving payment on behalf of a child, answer "Not Applicable." For the purpose of this survey, a child is:
- an unmarried minor (under age 18) child,
- an unmarried disabled child, even if he or she is over age 18.

5.

Earnings may be considered in determining whether the beneficiary is capable of self-support. Do not include Social Security
benefits.

6.

Answer Yes if you gave any of the annuity:
- to another person or to an institution to decide how to use the money, or
- to the beneficiary to decide how to use the money.

7. and 8. are self-explanatory.
9.

Please enter the beneficiary's Social Security Number (not your Social Security Number).

RI 38-115
Revised August 2010
Previous editions are not usable

1.

Is the beneficiary named on the fromt side of this form still living?

2.

Are you currently the representative payee for the above named annuitant?

3.

Where does the beneficiary live?

4.

Elsewhere (In the Remarks Section, please provide the name and
address of the person or facility caring for the beneficaiary.)
If you are receiving payment on behalf of a child, including adult disabled dependents, has the child married?

Yes

Yes

With you.

Date of Death (mm/dd/yyyy)

No (If no, please indicate the date of death.)

No (Please provide a name and address of the person responsible in the Remarks Section below.)

In his or her own home.

Yes (Please attach a copy of the marriage certificate.)

No

5a. Has the beneficiary earned money during the survey period?

5b. Amount Earned, if yes to
Question 5a.

Yes (Please enter earnings in 5b. Do not include Social
Security benefits.)
Did you turn over any of the annuity benefits to another person during the survey period?
No

6.

No
7.

Not applicable

$

Yes (Please explain in the Remarks Section.)

Did you place any of the money in savings for the future needs of the beneficiary?
No (Please explain in the Remarks Section.)

8.

Did you spend all of the money on the beneficiary?

9.

Beneficiary's Social Security Number

Yes

Yes (Please list the name and address of the financial institution
in the Remarks Section.)

No (Please explain in the Remarks Section.)

Remarks Section (Please use a separate sheet of paper if additional space is required.)

Warning: Any intentionally false statement in this response or willful misrepresentation relative thereto is a violation of the law
punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)
Signature of representative payee

Date (mm/dd/yyyy)

Daytime phone number (including area code) Email address

Social Security number or
Taxpayer Identification number

Privacy Act and Public Burden Statement
Title 5, chapter 83, U.S. Code, section 8347, and title 5, Chapter 84, U.S. Code, Section 8461, authorize the solicitation of the information to determine if we will be able to
continue paying you for the beneficiary. This information may be shared and is subject to verification, via paper, electronic media, or through the use of computer matching
programs, with national, state, local, or other charitable or social security administrative agencies to determine benefits under their programs, to obtain information necessary
for determination or continuation of benefits under this program, or to report income for tax purposes. It may also be shared and verified, as noted above, with law
enforcement agencies, when they are investigating a violation or potential violation of civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes the use of
the Social Security Number. Providing this information is voluntary; however, without your signature and all of the information requested, it may be impossible for us to
continue to pay you, and we may suspend these benefits.
We estimate completing this form takes approximately 20 minutes. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing
completion time, to the U.S. Office of Personnel Management, Retirement and Benefits Publications Team (3206-0208); Washington, DC 20415-3430. The OMB number,
3206-0208, is currently valid. OPM may not collect this information, and you are not required to respond, unless the number is displayed.
Reverse of RI 38-115
Revised August 2010