Form SSA-6230 Representative Payee Report (Child)

Social Security Administration
Representative Payee Report
Why You Received
This Form

We must regularly review how representative payees, including parents, stepparents,
and grandparents with custody of minor children, 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. The name(s) of the child(ren) we are asking about are shown in item 3 on the
form. If you receive benefits for children not named in item 3, we will send you
another form. Use this form only for the child(ren) named in item 3.
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

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-6230-F6 (08-2013) ef (08-2013)
Destroy Prior Editions

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Continued on the Reverse

u

Some
Definitions
To Help You

Benefits - The Social Security and/or SSI money that you receive.
Payee - You. The person who receives Social Security and/or SSI benefits for
someone else.
Beneficiary - The person for whom you receive Social Security and/or SSI benefits.
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 Does The
Child(ren)
Live With You?

Place an “X” in the “NO” box if any of the children named in item 3 did not live with
you in all of the months in the report period or any of the children are not living with
you now. Explain the change and provide the child(ren)'s current address under
REMARKS.
Note: Do not consider vacations, weekend or other short visits when you answer
this question.

QUESTION 3 - Accounting 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.
For Benefits

A.

Who Decided
How Benefits
Were Used?

Place an “X” in the “YES” box if you (the payee) decided how to use the money.
Place an “X” in the “NO” box if you turned over the full amount of benefits for any
of the children to another person who decided how to use the money. Explain under
REMARKS to whom the money was given and why.

B.

Amount
Spent

Show the total amount of benefits spent to care for all the children named in item 3.
This amount includes food, housing, clothing, medical and dental expenses,
recreation, and education.

C.

Unused
Benefits

Show the amount of benefits you saved for the child(ren) at the end of the report
period, including any interest earned. Show zeroes if you did not save any of the
benefits.

Form SSA-6230-F6 (08-2013) ef (08-2013)

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QUESTION 4 Savings Information

Answer this question if you showed an amount in 3.C.

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 account title you have
on the child(ren)’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 child(ren), but the child(ren) 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.

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).

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.

Your Responsibilities
As Representative
Payee

As payee, you must use the Social Security and SSI benefits you receive for the care
and well-being of the child(ren). In addition to reporting on the use of benefits, you
must report any changes which may affect the child'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 child:
• moves,
• marries,
• goes to work,
• is adopted,
• is imprisoned, or
• you are no longer responsible for the child.
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 the payee for the beneficiary, you must return any funds you
have saved to SSA.

Continued on the Reverse

Form SSA-6230-F6 (08-2013) ef (08-2013)

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The Privacy Act
And Paperwork
Reduction Act
Statements
See Revised Privacy
Act and Paperwork
Reduction Act
Statements attached.

Sections 205(j) and 1631(a) of the Social Security Act, as amended, authorize us to
collect the information on this form. The information you provided enables us to
account for the child(ren)'s payments and to ensure that you use the payments for the
child(ren)'s needs.
Your responses are voluntary. However, without the information, we may not be able
to continue sending the child(ren)'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. 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.
2.
3.
4.

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);
To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity and improvement of Social Security programs;
To respond to a request on your behalf from a Congressional office or the
Office of the President; and
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
21235-6401. 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.

Form SSA-6230-F6 (08-2013) ef (08-2013)

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Representative Payee Report

Form Approved
OMB No. 0960-0068

REPORT PERIOD

PAYEE'S NAME AND ADDRESS

SOCIAL SECURITY NUMBER

FROM:

TO:

ID

BIC

PC

DOC

CF

TAA

BIC1

CF

BSSN

BIC3

CF

BSSN

BIC2

CF

BSSN

BIC4

CF

BSSN

FP

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

This report is about the benefits you received between ___________ and ___________ for the child(ren)
named below. Please read the enclosed instructions before completing this report 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.

Did all the children named below live with you from ___________ to ___________? If NO,
please explain and provide the child(ren)'s current address in REMARKS on the back of
this form.

3.

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 for all the
children named below?
If NO, please explain in REMARKS on the back of this form.

B.

How much of the $__________ did you use for the care and support of the child(ren)
named below between ____________ and ___________?
u

C.

4.

NO

YES

NO

u
DOLLAR AMOUNT
(NO CENTS)

,

Show how much, if any, of the $_________ you saved for each child named below as of
__________? If none, show zeroes.
q

DOLLAR
AMOUNT

CHILD'S
NAME

BIC

YES

BIC

,
,

CHILD'S
NAME

DOLLAR
AMOUNT

,
,

If you showed an amount in 3.C. above, place an “X” in the boxes below to show how you are saving the child(ren)'s
benefits. If you have more than one account, you may mark more than one box in each section.

A. TYPE OF ACCOUNT
Savings/
Checking
Account

U.S.
Savings
Bonds

Certificates
of Deposit

Form SSA-6230-F6 (08-2013) ef (08-2013)

Treasury
Bills

B. TITLE OF ACCOUNT

Other

Child(ren)'s
Name by
Your Name

Your Name
for Child(ren)'s
Name

Continued on the Reverse

Other

u

FOR SSA USE ONLY

5.

ATT

MARK

SIG

UND1

UND2

OTH

Answer the question only if you answered “OTHER” in 4.A. or 4.B. on the front page. If you answered "OTHER" in 4.
A. or 4.B., show the type of account or investment and the title of the account or investment in which you saved each
child's benefits.

CHILD'S NAME

TYPE OF ACCOUNT OR INVESTMENT

TITLE OF ACCOUNT OR INVESTMENT

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

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

DATE

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).
SIGNATURE OF WITNESS
DATE
SIGNATURE OF WITNESS
Form SSA-6230-F6 (08-2013) ef (08-2013)

DATE