SSA-6234 Representative Payee Report (Organization)

6234

Representative Payee Report

See Revised PRA
Statement attached

FORM APPROVED
OMB NO. 0960-0691

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

REPORT PERIOD

SOCIAL SECURITY NUMBER

FROM:

TO:
FP

BENEFICIARY

ID

CF

BIC

D

TAA

TP

PF

CC

GS

BSSN

PC

FFS

DOC

DAA

MFA

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.
2.

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.

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

B.

Did you (the payee) charge the beneficiary a fee for payee or
guardianship services you provided between
and
?
If YES, how much of the $
for these services between

did you collect from the beneficiary
and
?

C.

How much of the $
did you spend for the beneficiary's
food and housing between
and
?

D.

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
?

E.

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

FORM SSA-6234-OCR-SM (02-2012)

YES

NO

YES

NO

YES

NO

DOLLAR AMOUNT
(NO CENTS)

Continued on the Reverse

FOR SSA USE ONLY

6234B

3.

ATT

MARK

SIG

UND1

UND2

OTH

If you showed an amount in 2.E. (front page), 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
Account

4.

U.S. Savings
Bonds

Certificates
of Deposit

Collective
Savings/
Checking
Account

Treasury
Bills

B. TITLE OF ACCOUNT
Other

Beneficiary's Name
by Your Name

Your Name for
Beneficiary's Name

Other

Answer this question only if you answered “OTHER” in 3.A. or 3.B. above. If you answered
“OTHER” in 3.A. or 3.B., show the type of account or investment, or the title of the account in
which the benefits are saved.

A. TYPE OF ACCOUNT

B. TITLE OF ACCOUNT

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 any one 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

5.

7.

PRINT JOB TITLE

6.

FORM SSA-6234-OCR-SM (02-2012)

DAYTIME TELEPHONE NUMBER(S)
(Include area code and extension)

8.

Area Code

Extension

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.