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.ssa.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. Use black ink.
2. Keep your numbers and “X’s” inside the boxes.
3. Do not use dollar signs.
4. Show money amounts in dollars only. Do not show cents.
For example, show $1,540.30 like this:
DOLLAR AMOUNT

1 , 5 4 0
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-F6 (08-2013) ef (08-2013)
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Continued on the Reverse

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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.

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.

Form SSA-623-F6 (08-2013) ef (08-2013)

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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-F6 (08-2013) ef (08-2013)

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Your Responsibilities As
Representative Payee
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.
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.

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

See Revised Privacy Act and Paperwork
Reduction Act Statements attached.

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 to enable
us to account for the beneficiary's payments and to ensure
that you use the payments for the beneficiary's needs.
Your responses are voluntary. However, without the
information, we may not be able to continue sending the
beneficiary's payments to you.
We rarely use the information you give us for any purpose
other than for accounting purposes. However, we may use
it for the administration and integrity of Social
Security programs.

Form SSA-623-F6 (08-2013) ef (08-2013)

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 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);
2. To facilitate statistical research, audit , or
investigative activities necessary to assure the
integrity and improvement of Social
Security programs;
3. To respond to a request on your behalf from a
Congressional office or the Office of the
President; and
4. To other Federal agencies and our contractors,
including external data sources, to assist us in
efficiently administering our programs.
We may also use the information you give us in 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.
A complete list of routine uses for this information is
available in our Privacy Act System of Records Notice
(SORN) entitled, Master Representative Payee File
(60-0222). The complete SORN, additional information
about this form, routine uses of information, and our
programs and systems are available online at
www.socialsecurity.gov or 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
control number. We estimate that it will take about 15
minutes to read the instructions, gather the facts, and
answer the questions. You may send comments on our time
estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235 . Send only comments relating to our time
estimate to this address, not the completed form.

If You Have Any Questions
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.

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Representative Payee Report

FORM APPROVED
OMB NO. 0960-0068
SOCIAL SECURITY NUMBER

REPORT PERIOD

PAYEE'S NAME AND ADDRESS

FROM:

TO:

BENEFICIARY
ID

FP

D

BIC

GS

CC

PC

CF

DOC

TAA

PF

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

TP

BSSN

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

1.
2.
3.

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.
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.
and

Benefits paid to you between

Benefits you reported as saved on last year's report

A.
B.
C.
D.
4.

NO

YES

NO

=$
=$

Total Accountable Amount
=$
Did you (the payee) decide how the
was
spent or saved?
If NO, please explain in REMARKS on the back of this form.
How much of the
food and housing between
?

YES

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did you spend for the beneficiary's
and

How much of the
did you spend on other things
for the beneficiary such as clothing, education, medical and
dental expenses, recreation, or personal items
between
and
?
How much, if any, of the
did you save for the
beneficiary as of
? If none, show zeroes.

u

DOLLAR AMOUNT
(NO CENTS)

,

,

u
u

,

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

Savings / Checking U.S. Savings
Account
Bonds

Certificates
of Deposit

Form SSA-623-F6 (08-2013) ef (08-2013)

Collective Savings/
Checking Account

B. TITLE OF ACCOUNT
Treasury
Bills

Other

Beneficiary's Name
by Your Name

Your Name for
Beneficiary's Name

Continued on the Reverse

Other

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FOR SSA USE ONLY
ATT

MARK

SIG

UND1

UND2

OTH

this question if you answered "OTHER"
5. A. Answer
in 4.A. on the front page. If you answered
"OTHER" in 4.A., show the type of account or

TYPE OF ACCOUNT

this question only if you answered
B. Answer
"OTHER" in 4.B. on the front page. If you
answered "OTHER" in the 4.B., show the

TITLE OF ACCOUNT

investment in which the benefits are saved.

title of the account in which the benefits are
saved.

u

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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.

DAYTIME TELEPHONE NUMBER(S)
(Include area code)

6.

8.

Area Code

WITNESS SIGNATURES ARE REQUIRED ONLY IF THE PAYEE'S SIGNATURE ABOVE
HAS BEEN SIGNED BY MARK (X).
DATE
SIGNATURE OF WITNESS
SIGNATURE OF WITNESS

Form SSA-623-F6 (08-2013) ef (08-2013)

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