Form SSA-2001-F6 Representative Payee Report - Special Veterans Benefits

SOCIAL SECURITY ADMINISTRATION
REPRESENTATIVE PAYEE REPORT-SPECIAL VETERANS BENEFITS
Return the attached form to:

Please complete the attached REPRESENTATIVE PAYEE REPORT. You must complete this report if you wish to
continue to receive Special Veterans Benefits (SVB) payments for the beneficiary named on the first page of the
report. The facts you give up help us determine if you are using the payments properly.
What You Need
To Do

Please read the instructions before you complete the report. Then,
complete the report and send it to us in the enclosed envelope within
30 days. If you do not return it promptly, we may stop sending payments
to you.

General
Instructions

Please follow these instructions:
• Use black ink or a #2 pencil to complete the report.
• Print your answers, except in the signature block.
• Place “X's” in the appropriate “YES” or “NO” boxes.
• Use the “Remarks” section on the back of the report to provide
additional information.
• Be sure to sign the report in item 6.
• If you have been receiving these benefits for the beneficiary for
less than 15 months, answer the questions as they relate to the months
for which you did receive the benefits.

HOW TO COMPLETE THE REPORT
The numbers below match the numbered items on the report.
Item 1Payee Address
Changes

Show your new address if it is different from the one that is shown in the
block on the first page of this report.

Item 2Beneficiary
Custody Changes

If the beneficiary lived apart from you during any part of the past
15 months, answer “YES” and also complete (a) through (d) of item 2.
If the beneficiary continued to live with you during the entire period,
answer “NO.”

Form SSA-2001-F6 (01-2007) Destroy Prior Editions

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Continued on the Reverse

Item 3Who Decided
How Benefits
Were Used

If you decided how the SVB payments were used or saved for the beneficiary,
answer “YES.” If someone else or the beneficiary decided how the benefits
were used or saved, answer “NO,” and show the name of the person who made
this decision.

Item 4Use of Benefits

If all of the SVB payments received during the past 15 months were used for
the beneficiary, answer “YES” and go on to item 6. If some or all of the
payments were saved for the beneficiary, answer “YES” and be sure to
complete item 5. If some or all of the payments were neither used nor
saved for the beneficiary, answer “NO” and explain what was done with
those payments.

Item 5Savings
Information

Answer item 5 if any payments are saved for the beneficiary.
A. Check “Bank Account” or “Other” to indicate how the payments are
saved. If you check “Other,” explain how the payments are saved.
B. Show the title of the account or the ownership name that appears on the
account in which the payments are saved.

Item 6Payee's
Signature

Sign your name here and enter the date. If you sign by a mark (X), please
have a witness sign his or her name and show his or her address and date in
the space below item 7.

Item 7Relationship To
The Beneficiary

Show your relationship to the beneficiary, such as “parent,” “brother,”
“friend” or “legal guardian.” If you represent an institution or agency,
show the name of the institution or agency and your job title.

Your Job As A Representative Payee

You must also report to us promptly if the beneficiary:

As a representative payee, you must use the SVB
payments you receive for the care and well-being of
the beneficiary. This is true whether you are a
relative, friend, court-appointed guardian or official of
an agency or institution. You must keep yourself
informed of the beneficiary's needs so you can decide
how the benefits should be used. You must account
for the use of the benefits on the attached report. This
accounting will be reviewed by the Social Security
Administration and is subject to verification.
Therefore, you should keep a record of the amount of
benefits you received and how you used them
(receipts, cancelled checks, etc.).

• dies;
• returns to or visits the United States for a calendar
month or longer;
• receives any other benefit income (pension,
annuity, workers compensation, etc.) or the amount
of the benefit income received changes;
• has been deported or removed from the United
States;
• is under a warrant of arrest that remains unsatisfied
for a felony crime in the United States, or in U.S.
jurisdictions that do not define crimes as felonies,
for a crime that is punishable by death or
imprisonment for a term exceeding one year;

You must notify the Social Security Administration
when the beneficiary changes residence or you are no
longer responsible for the care and welfare of the
beneficiary.

• is violating a condition of parole or probation
imposed under Federal or State law.
Form SSA-2001-F6 (01-2007)

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See Revised Privacy Act and PRA Statements Attached
Privacy Act Notice

Paperwork Reduction Act Statement

The Social Security Administration is authorized to
collect the information requested on this form under
Section 807 of the Social Security Act. The
information you provide enables SSA to account for
the beneficiary's payments and ensures that the
beneficiary's needs are being met. If you do not
complete and return this form, we may not be able to
continue sending the beneficiary's payments to you.

This information collection meets the clearance
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
10 minutes to read the instructions, gather the
necessary facts and answer the questions. You may
send comments on our time estimate above to: SSA,
6401 Security Blvd. Baltimore, MD 21235-6401. Only
comments relating to our time estimate should be
provided, not the completed form.

Although the information you furnish on the
application is rarely used for any other purpose than
stated, there is a possibility that information may be
disclosed to another person or to another
governmental agency as follows:

If You Have Any Questions

(1) to enable a third party or an agency to assist the
Social Security Administration in establishing rights
to Special Veterans Benefits and (2) to comply with
Federal laws requiring the release of information from
Social Security records (e.g., to the Department of
Veterans Affairs).

If you have any questions, you may contact any U.S.
Embassy or consulate or the nearest U.S. Social
Security office. If you live in the Philippines, you may
contact the U.S. Veterans Affairs Regional Office,
SSA Division, American Embassy at 1131 Roxas
Boulevard, 0930 Manila.

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 U.S. Social Security offices. If you
want to learn more about this, contact any U.S. Social
Security office.

Form SSA-2001-F6 (01-2007)

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REPRESENTATIVE PAYEE REPORT-SPECIAL VETERANS BENEFITS
FORM APPROVED
Social Security Administration
OMB NO. 0960-0621
Payee's Name and Address

Beneficiary's Name

For SSA Use Only

Beneficiary's SSN

Report Period

1st Request

2nd Request

FROM:

TOP

CC

G

TO:

Date Received
(Month

Year)

Day

(Month

Day

Year)

This report is about the Special Veterans Benefits (SVB) you received for the beneficiary named above. Please read
the attached instructions to help you answer each item.
IMPORTANT: COMPLETE, SIGN AND RETURN THIS FORM IN THE ENCLOSED ENVELOPE
WITHIN 30 DAYS. IF YOU DO NOT RETURN IT PROMPTLY, WE MAY STOP SENDING PAYMENTS
TO YOU.
1. If you have changed your address from the one shown above, please print your new address below.

2. Did the beneficiary live apart from you during any part of the past 15 months?
If “YES” , please complete (a) through (d) below.
(a) Date the beneficiary left
Month

Day

YES

NO

(b) Reason for leaving

Year

(c) Date the beneficiary returned, if applicable,
Month

Day

Year

(d) If the beneficiary is currently not living with you, show the name of the person with whom the beneficiary is
living and the address where he/she can be contacted.

3. Did you decide how the SVB payments were used or saved for the beneficiary?
If “NO ,” show the name of the person who decided how to use or save the payments.

Form SSA-2001-F6 (01-2007)

Continued on the Reverse

YES

NO

4. Were all the SVB payments received during the past 15 months used for the beneficiary and/or saved for the
beneficiary?
YES
NO

IF ANY SVB PAYMENTS ARE SAVED FOR THE BENEFICIARY, COMPLETE ITEM 5 BELOW.
5. A. TYPE OF ACCOUNT
Show the manner in which any SVB payments not used for the beneficiary are saved:
Bank Account

Other
If “Other,” explain below how the payments
are saved.

B. TITLE OR OWNERSHIP
Show the title or ownership of the account in which any SVB payments are being saved (for example, show
“Beneficiary's Name by Your Name, ” “Your Name for Beneficiary's Name ” or another form of title or
ownership that is shown on the account):

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.
6. Payee's Signature (Note: If this form is signed with a mark (X), a witness must sign below.) Date

7. Relationship to Beneficiary or Title

Telephone Number

Witness signature is required only if the payee's signature above has been signed by a mark (X).
Signature of witness

Form SSA-2001-F6 (01-2007)

Address (include Zip Code)

Date

SSA will insert the following revised Privacy Act and PRA Statements into the form as soon as
possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 807(a) and 807(h), of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to account for the beneficiary’s payments
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 prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than make a determination
regarding benefits eligibility. 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 ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notice 60-0103, entitled Supplemental Security Income Record
and Special Veterans Benefits; and, 60-0273, entitled Social Security Title VIII Special Veterans
Benefits Claim Development and Management Information System. Additional information
about these and other system of records notices and our programs are available online at
www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State or local government
agencies. Information from these matching programs can be used 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.
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 10 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.