Form SSA-623 Representative Payee Report (Adult)

6232

Representative Payee Report

See Revised PRA
Statement attached

Social Security Administration, P.O. Box 6230, Wilkes-Barre, PA 18767-9956
PAYEE'S NAME AND ADDRESS

FORM APPROVED
OMB NO. 0960-0068

SOCIAL SECURITY NUMBER

REPORT PERIOD
FROM:

TO:
FP

BENEFICIARY

BIC

ID

CF

D

TAA

TP

CC

PF

GS

PC

DOC

BSSN

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 beneficiary,
. Please read the enclosed instructions before completing this form 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.
3.

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.
Benefits paid to you between
and
Benefits you reported as saved on last year's report.

=$
=$

Total Accountable Amount

=$

A.

4.

NO

YES

NO

Did you (the payee) decide how the $
was spent or saved?
If NO, please explain in REMARKS on the back of this form.

B.

How much of the $
housing between

C.

How much of $
did you spend on other things for the
beneficiary such as clothing, education, medical and dental expenses,
recreation, or personal items between
and
?

D.

How much, if any, of the $
did you save for the beneficiary as of
? If none, show zeros.

DOLLAR AMOUNT
(NO CENTS)

did you spend for the beneficiary's food and
and
?

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.

B. TITLE OF ACCOUNT

A. TYPE OF ACCOUNT
Savings/
Checking
Account

YES

U.S. Savings
Bonds

Certificates
of Deposit

Collective Savings/ Treasury
Bills
Checking Account

FORM SSA-623-OCR-SM (02-2012)

Other

Beneficiary's Name
by Your Name

Your Name for
Beneficiary's Name

Continued on the Reverse

Other

FOR SSA USE ONLY

6232B

5.A.
B.

ATT

MARK

SIG

UND1

UND2

OTH

Answer this question only if you answered “OTHER” TYPE OF ACCOUNT
in 4.A. on the front page. If you answered “OTHER” in
4.A., show the type of account or investment in which
the benefits are saved.
Answer this question only if you answered “OTHER”
TITLE OF ACCOUNT
in 4.B. on the front page. If you answered “OTHER” in
4.B., show the title of the account in which the benefits
are saved.

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.
DATE
PAYEE’S SIGNATURE
(If signed by mark (“X”), two witnesses must sign below)

7.

DAYTIME TELEPHONE NUMBER(S)

6.

(Include area code)

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

DATE

FORM SSA-623-OCR-SM (02-2012)

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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
15 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments regarding this burden estimate or any other aspect of this collection,
including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.