Form SSA-6233-BK Representative Payee Report of Benefits and Dedicated Ac

Representative Payee Report of Benefits and Dedicated Account

SSA-6233-BK - Revised

Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665

OMB: 0960-0576

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Form SSA-6233-BK (11-2020)
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Social Security Administration

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OMB No. 0960-0576

Representative Payee Report of Benefits and Dedicated Account
Payee's Name and Address

Report Period
From:

To:

Social Security Number
Beneficiary
Please review the above mailing address and correct if necessary.

This report is about the benefits you received for the beneficiary and those which were deposited in the
dedicated account during the report period shown above. It also includes any money you reported as
saved from a prior report period. Please read the enclosed instructions before completing this form to
help you answer each question.
NOTE: If you are a payee who is exempt from the annual accounting process, only complete questions 6
through 8.
1. Were you (the payee) convicted of a crime considered to be a felony
during the report period shown above?
If Yes, please explain the type of crime:

2. Did the beneficiary continue to live alone, or with the same person, or
in the same institution during the report period shown above?

Yes

No

Yes

No

Yes

No

If No, please explain and provide the beneficiary's current address:

3. Benefits paid to you during the report period

=$

Benefits you reported saved from prior years

=$

Total Accountable Benefit Amount

=$

A. Did you (the payee) decide how the total accountable
amount was spent or saved?
If No, please explain:

Form SSA-6233-BK (11-2020)

3. B. How much of the total accountable amount did you spend
for the beneficiary's food and housing during the report
period?
C. How much of the total accountable amount did you spend
on other things for the beneficiary such as clothing,
education, medical and dental expenses, recreation, or
personal items during the report period?

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DOLLAR AMOUNT
(No cents)

DOLLAR AMOUNT
(No cents)

If the beneficiary lives in an institution or other care facility and you spent less than $360 a year
for the beneficiary's personal needs, please explain how his/her needs were met:

D. How much, if any, of the total accountable amount did you
save for the beneficiary as of the last month in the report
period? If none, show zeros.

DOLLAR AMOUNT
(No cents)

4. 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
Account
B. TITLE OF ACCOUNT
Beneficiary's Name
by Your Name

U.S. Savings
Bond

Certificates of
Deposit

Your Name for
Beneficiary's Name

Collective Savings/
Checking Account

Other

Other

5. A. If you answered "Other" in 4.A., show the type of account or investment in which the benefits are
saved:

B. If you answered "Other" in 4.B., show the title of account in which the benefits are saved:

Form SSA-6233-BK (11-2020)

6. Past-due SSI benefits deposited by SSA in dedicated account

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=$

Balance in dedicated account as you reported on a prior report

=$

Total Dedicated Account Amount

=$

Did you deposit any money into the dedicated account during
the report period?

Yes

No

Yes

No

If Yes, please provide the date and amount of each deposit:

7. A. Did you take any money out of the dedicated account during
the report period?

If Yes, please explain what items and/or services you purchased and the amount of each purchase:

B. Were these purchases for medical treatment, or education
or job skills training?

Yes

No

If No, please explain how they benefited the beneficiary and are related to his/her impairment(s):

DOLLAR AMOUNT
(No cents)

8. What is the balance, including any interest earned, in the
dedicated account as of the last month in the report period?
If none, show zeros.

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 statement about a material fact in this information, or causes someone
else to do so, commits a crime and may be subject to a fine or imprisonment.
Payee's Signature (If signed by mark (X), two witnesses must sign below.) Date

Relationship to Beneficiary or Title

Telephone Number
(including 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-6233-BK (11-2020)

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Representative Payee Report of Benefits and Dedicated Account
Why You Received This Form
We must regularly review how representative payees used the benefits they received on behalf of 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 required to establish a separate (we refer to it as
a dedicated) account in which we direct deposited certain past-due SSI benefits. You were informed of the
duties and responsibilities of a representative payee, including keeping a record of all the money taken from
the dedicated account and receipts for all the items and/or services purchased. We must regularly review
this account for additional deposits and to ensure that the items and/or services purchased are in
compliance with the law. As part of this review, you need to answer the questions on the enclosed form. It is
called Representative Payee Report of Benefits and Dedicated Account, SSA-6233-BK.
Effective April 13, 2018, the following representative payees are only required to complete questions 6
through 8 of the Representative Payee Report of Benefits and Dedicated Account, SSA-6233-BK:
• natural or adoptive parents of a minor child who reside in the same household;
• legal guardians of a minor child who reside in the same household;
• natural or adoptive parents who reside in the same household with an adult child who has a disability;
and
• spouses.
You should keep these records (e.g., bank statements and canceled checks) along with receipts for two
years from the time you complete the form. Do not submit any records with the completed form. If we have
any questions, we will contact you.
What You Need To Know
Please read the instructions below before you complete the report. Then, complete the report and send it
to us in the enclosed envelope within 30 days. If you do not return it promptly, we may stop sending
payments to you.
General Information
To help us process your report, please follow these instructions:
1. Do not use dollar signs.
2. Show money amounts in dollars only. Do not show cents. For example, show $1,540.30 like this:
DOLLAR AMOUNT
(No cents)
$1,540

3. Be sure you, the representative payee, sign the form.
Some Definitions To Help You
Benefits - The Social Security and/or SSI money 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.

Form SSA-6233-BK (11-2020)

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Some Definitions To Help You (Continued)
Report Period - The 12-month period shown on the report for which you must account for the benefits you
received and report on the dedicated account.
Total Accountable Benefit Amount - The amount of benefits paid to you during the report period plus any
amount you reported as saved on last year's report. Note: This amount does not include any SSI
past-due benefits SSA deposited into the dedicated account.
Dedicated Account - This is the savings, checking or money market account you were required by law to
establish for certain past-due SSI Benefits. We call it a dedicated account because the law also
restricts the items and/or services you can buy with money from the account.
Total Dedicated Account - The amount of past-due SSI benefits SSA direct deposited into the dedicated
account plus the account balance as you reported on last year's report.
How To Complete The SSA-6233-BK
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. 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.
Question 3 - Accounting For Benefits
The total accountable benefit amount includes the benefits you received during the report period plus any
benefits you reported as saved on last year's report. Note: It does not include the money that was
deposited by SSA or you into the dedicated account.
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 in the
space provided.
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 charge by 12 and show this
amount.

Form SSA-6233-BK (11-2020)

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C. Personal Items
Show the total amount of benefits spent for the beneficiary on clothing, medical/dental care, education, and
recreational items like toys, movies, cameras, radios, candy, stationery, 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 in the space provided.
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 zeros if you did not save any of the benefits. Note: Do not include the
money saved in the dedicated account.
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.
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.
Question 6 - Total Dedicated Account Amount
The total dedicated account amount includes the past-due SSI benefits SSA deposited into the account
during the report period plus the balance in the account as you reported on last year's report.
Deposits Into Dedicated Account
Place an "X" in the "Yes" box if you deposited any money into the dedicated account during the report
period. Show the date and amount of each deposit. Place an "X" in the "No" box if you did not deposit any
money into the account.

Form SSA-6233-BK (11-2020)

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Question 7
A. Money Taken Out Of Dedicated Account
Place an "X" in the "Yes" box if during the report period you took money out of the dedicated account.
Explain what items and/or services you purchased and the amount of each purchase. Place an "X" in the
"No" box if no money was removed from the account.
B. How Is Purchase Related To Impairment?
Answer this question if you checked "Yes" in 7.A. Place an "X" in the "Yes" box if the items and/or services
purchased were for medical treatment, or education or job skills training. Place an "X" in the "No" box if the
purchases were for something else and explain how the purchases benefited the beneficiary and are related
to his/her impairment(s).
Question 8 - Dedicated Account Balance
Show the balance in the dedicated account at the end of the report period, including any interest earned.
Show zeros if there is no money in the account.
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.

Relationship To The Beneficiary
Show your relationship to the beneficiary. Some examples include: parent, brother, friend. If you are the
beneficiary's legal guardian, show "legal guardian". If you represent a bank, institution or agency, show your
job title (e.g., administrator, bookkeeper, etc.).
Your Responsibilities As Representative Payee
As representative 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 and the dedicated account, you must report any changes
which may affect the beneficiary's eligibility for benefits, or the payment amount. You should report these
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:
•
•
•
•
•
•
•
•

moves (especially if he/she enters or leaves a hospital or other institution),
marries,
goes to work,
is imprisoned,
dies,
is adopted,
no longer needs a payee, or
you are no longer responsible for the beneficiary.

As 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.

Form SSA-6233-BK (11-2020)

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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(j) and 1631(a) of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
result in the termination of benefits or payments.
We will use the information to account for the use of benefits and payments and ensure the beneficiary’s
needs are met. We may also share your information for the following purposes, called routine uses:
• To a claimant, or other individual authorized to act on his or her behalf, information concerning the
status of his or her representative payee or the status of the application of a person applying to be his
or her representative payee, and information pertaining to the address of a representative payee
applicant or a selected representative payee, when this information is needed to pursue a claim for
recovery of misapplied or misused benefits; and
• To agencies or entities with responsibility for investigating or addressing possible financial exploitation
of, an immediate health or safety threat to, or other serious risk to the well-being of the beneficiary, for
referral, when these issues are identified during a representative payee review.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person’ eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0222,
entitled Master Representative Payee File, as published in the Federal Register (FR) on April 22, 2013, at
78 FR 23811, and subsequently modified on July 3, 2018, at 83 FR 31251. Additional information, and a full
listing of all our SORNs, is available on our website at www.ssa.gov/privacy.

See Revised Privacy Act &
PRA Statements attached
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 question unless we display a valid
Office of Management and Budget (OMB) control number. We estimate that it will take about 20 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.

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.


File Typeapplication/pdf
File TitleSSA-6233-BK
SubjectRepresentative Payee Report of Benefits and Dedicated Account
AuthorSSA
File Modified2021-11-01
File Created2020-11-19

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