RI 38-115 Representative Payee Survey_Revised

OMB Approval 3206-0208

Representative Payee
Survey

Show any address change next to your address below.

Date
Survey period

U.S. Office of Personnel Management
Retirement Surveys & Students Branch
1900 E Street, NW - Room 2416
Washington, DC 20415-0001

Claim number
Case name

Annuitant's name

The purpose of this questionnaire is to ensure that Federal retirement benefit payments are being used in the best interests of the annuitant
named above. The Office of Personnel Management (OPM) previously approved you as the Representative Payee because a determination
was made that the annuitant was incapable of handling his or her own affairs. The information below may assist you while completing the
survey:
• If you are a court-appointed fiduciary for the annuitant and are required to make an annual accounting to the court, OPM may be
able to accept your annual accounting in lieu of the Representative Payee Survey (RI 38-115). If you do elect to submit an annual
accounting in lieu of this Representative Payee Survey, please ensure that the accounting completely addresses all the following
survey questions.
• If you are completing this form on behalf of an organization, please provide your organization's Taxpayer Identification Number
(TIN) in the designated area.
• The annuitant's earnings may be considered in determining his or her continued eligibility for benefits and/or may affect their
status as an individual incapable of self-support. Do not include Social Security benefits, Federal retirement and/or survivor
benefits. Report only earned income for the annuitant.
• For the purpose of this survey, a child is either an unmarried minor (under age 18), or an unmarried disabled dependent child
(determined to be disabled prior to age 18, even if he or she is now over age 18).
• If the annuitant is deceased, you are required to return all payments received after the death of the annuitant to the U.S.
Department of the Treasury.
Please read and respond to each question in the space provided. The completed form can be returned in the enclosed envelope to the
address shown in the upper right-hand corner of this notice. Please return the completed form within 30 days after the date of this
survey or we will have to stop paying these benefits. We appreciate your cooperation.
If you need another form or have questions, please call (202) 606-0249. Individuals calling from outside the Washington, DC area
can call our Retirement Information Office toll free at 1-888-767-6738. You can also go to www.opm.gov for additional information
or write to OPM at the address shown above.
Retirement Surveys and Students Branch

RI 38-115
Revised September 2022
Previous editions are not usable.

The survey pertains to the benefits you received as Representative Payee for
from

through

(mm/dd/yyyy)

previous reporting period.

(Annuitant's name)

. It also includes any money you reported as saved from a

(mm/dd/yyyy)

1. Is the annuitant listed above still living? If no, provide date of death and return all payments received after death to the U.S. Department
of Treasury.
Date of Death (mm/dd/yyyy)

No (Please indicate the date of death.)

Yes

2. Are you currently serving as the Representative Payee for the above-named annuitant?
No (Please provide a name and address of the person responsible.)

Yes

3. Are you, or anyone else, currently serving as either a Representative Payee, or Court-Appointed Conservator, Guardian or Fiduciary
for any other Federal agency for the annuitant listed above? If yes, please explain:

4. Have you been dismissed as a Representative Payee or convicted of a felony or crime related to misuse of funds?
(This does not apply to Organizational Representative Payees.)
Yes (Please explain the felony.)

No

5. Have you (the Representative Payee) filed for bankruptcy during this survey period?
Yes (Please explain the bankruptcy.)

No

6. Where does the annuitant live?
With you

In his or her own home

(Please provide the name and address of
Elsewhere the person/facility caring for the annuitant.)

7. If you are receiving payment on behalf of a child, including an adult disabled dependent, has the child married? Or if you are receiving
payment on behalf of a surviving spouse, have they re-married prior to age 55?
Yes (Please attach a copy of the marriage certificate.)

8. Has the child or adult disabled dependent earned money during
the survey period?
Yes

No

Not Applicable

8a. Amount Earned (e.g. W-2 wages), if yes to Question 8.

(Please enter earnings in 8a. Do not include
Social Security benefits or any annuities.)

No

$

8b. Where does the annuitant work, if yes to Question 8?

RI 38-115
Revised September 2022

9. Did you turn over any of the annuity benefits to another person during the survey period?
Yes (Please explain below.)

No

10. How much did you receive in annuity benefits during the reporting period?
$
11. How much was spent on food, housing, and clothing during the reporting period?
$
12. How much of the benefits paid were spent on other things, such as education, medical, recreational, or personal items?
$
13. Was this decision to spend or save the annuitant's benefits made only by you?
Yes

No (Please explain below.)

14. How much did you save from the previous reporting period? $
15. Did you save any of the money for the future needs of the annuitant this survey period?
Yes (Please provide account information below.)

No (Please explain below.)

16. Where are the annuity payments deposited and saved? Specify the type of account (checking, savings, etc.), who has access to the
account, and the name on the account.

17. What is the current balance in the account? $
18. Annuitant's Social Security Number
Warning: Any intentionally false statement in this response or willful misrepresentation relative thereto is a violation of the law
punishable by a fine of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 U.S.C. 1001)
Signature of Representative Payee

Daytime phone number (including area code)

Email address

Organization Taxpayer Identification Number

Date (mm/dd/yyyy)

Privacy Act Statement
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why OPM is requesting the information on this form. Authority: OPM is authorized to collect the information
requested on RI 38-115, pursuant to Title 5 U.S. CFR, Parts 8347(a) and 8461(g), which discuss the law and regulations relating to the payment of retirement benefits. OPM is authorized to collect
your Social Security Number by Executive Order 9397 (November 22, 1943), as amended by Executive Order 13478 (November 18, 2008). Purpose: This form is used to collect information about
how the monies OPM has paid to a representative payee have been used or conserved for the benefit of the incompetent annuitant. Routine Uses: The information requested on this form may be
shared as a "routine use" to other Federal agencies and third-parties when it is necessary to process your application. For example, OPM may share your information with other Federal, state, or local
agencies and organizations in order to determine benefits under their programs, to obtain information necessary for a determination of your disability retirement benefits, or to report income for tax
purposes. OPM may also share your information with law enforcement agencies if it becomes aware of a violation or potential violation of civil or criminal law. A complete list of the routine uses can
be found in the OPM/CENTRAL 1 Civil Service Retirement and Insurance Records system of records notice, available at www.opm.gov/privacy. Consequences of Failure to Provide Information:
Failure to provide this information would hamper OPM's efforts to oversee the payment of annuities to persons who are charged with using the money for the benefit of someone else.

Public Burden Statement
We estimate completing this form takes approximately 20 minutes. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the
U.S. Office of Personnel Management, Retirement Services Publications Team (3206-0208), Washington, DC 20415-0001. The OMB number, 3206-0208, is currently valid. OPM may not collect this
information, and you are not required to respond, unless the number is displayed.

RI 38-115
Revised September 2022