Statement of Care and Responsibility for Beneficiary

Social Security Administration

Form Approved
OMB No. 0960-0109

TOE 250

STATEMENT OF CARE AND RESPONSIBILITY FOR BENEFICIARY
In replying, use this address:
SOCIAL SECURITY ADMINISTRATION

NAME AND ADDRESS OF CUSTODIAN

TELEPHONE NUMBER
DATE
IDENTIFYING INFORMATION
(If different from patient)

SSA CONTACT

NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

APPLICANT'S NAME AND ADDRESS

BENEFICIARY NAME
BENEFICIARY SOCIAL SECURITY NUMBER
APPLICANT'S RELATIONSHIP TO BENEFICIARY

YOUR HELP IS NEEDED
The applicant shown above has applied to be appointed representative payee for the above beneficiary. We need you to
complete this form and return it to us in the enclosed envelope. The information you provide will help us decide if we should pay
this person directly or if he or she needs a representative payee to handle funds. If a representative payee is needed, you will
help us to determine the responsibility assumed by the applicant for the beneficiary's well-being. Thank you for your help.
1. DATE BENEFICIARY BEGAN LIVING WITH YOU
(month/day/year)

HOW LONG WILL
BENEFICIARY LIVE
WITH YOU?

REASON BENEFICIARY DOES NOT LIVE
WITH THE APPLICANT

2. If the beneficiary is not living with you, where and with whom is the beneficiary living and when did he or she leave your care?

3. Do you believe the beneficiary is capable of managing or directing the management of benefits in his or her own best interest?
By capable we mean the beneficiary:
• Is able to understand and act on the ordinary affairs of life, such as providing food, housing, clothing, etc., and
• Is able, in spite of physical impairments, to manage funds or direct others how to manage them.
Yes
No
If "No" or "Unsure," please provide a brief explanation.

Form SSA-788 (01-2015) UF (01-2015)
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Unsure

PER MONTH

4. Please show the approximate amount you charge each month for the beneficiary's room,
board, and care

$

5. Does (or did) any agency, including the applicant, pay toward the cost of the beneficiary's care and maintenance?
Yes
No
If "Yes" please supply the information requested below.
NAME AND ADDRESS

AMOUNT CONTRIBUTED

HOW OFTEN CONTRIBUTIONS ARE MADE

6. How often and when was the last time the applicant did any of the things shown below for the beneficiary?
VISIT

SENDS CLOTHING

SENDS OTHER GIFTS

WRITES LETTERS

How often?
Last Time?
7. List the names and relationship of any other relatives or close friends who have provided support and /or show interest in the
claimant. Describe the type and amount of support and/or how interest is displayed.
NAME

ADDRESS/PHONE NO.

RELATIONSHIP

8. Does the beneficiary have any unmet personal needs at this time?

Yes

SUPPORT/INTEREST

No

If "Yes," please list the needs.

9. In emergency situations, where the beneficiary needs surgery, becomes seriously ill, etc., who would you notify?
NAME

ADDRESS

10. Does the applicant give you any instructions for the care of the beneficiary?

Yes

No

If "Yes," explain what those instructions are, how often they are given, and what the applicant does to see that they are
carried out.

Form SSA-788 (01-2015) UF (01-2015)

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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 205(j) of the Social Security Act, as amended, authorize us to collect this information. We will use the
information you provide to help us establish your suitability to serve as a representative payee.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information could prevent us from
making a decision to select you as a representative payee.
We rarely use the information you supply for any purpose other than for establishing payee suitability. We may also disclose
information to another person or to another agency in accordance with approved routine uses, which include but are not limited to
the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or
coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government
Accountability Office and Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and
local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of
Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).
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 payments or
delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Records Notice entitled, Master Representative
Payee File, 60-0222. This notice, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.
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.
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.
SIGNATURE OF PERSON MAKING STATEMENT
SIGNATURE (First name, middle initial, last name) (Write in ink)

DATE (Month, day, year)

SIGN
HERE

TELEPHONE NUMBER (Include area code)

MAILING ADDRESS (Number and street, Apt. No., P.O. Box, or Rural Route)
CITY AND STATE

ZIP CODE

NAME OF COUNTY (IF ANY)

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the individual must sign below, giving their full address.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS
ADDRESS (No. & Street, City, State, and ZIP Code)

Form SSA-788 (01-2015) UF (01-2015)

ADDRESS (No. & Street, City, State, and ZIP Code)

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REMARKS: (This space may be used for explaining any answers to the questions. If you need more space, attach a
separate sheet)

Form SSA-788 (01-2015) UF (01-2015)

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