Ssa-11-bk (1-2014)

Form SSA-11-BK (01-14).pdf

Application to Act as Representative Payee

SSA-11-BK (1-2014)

OMB: 3220-0052

Document [pdf]

Download: pdf | pdf

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0014
FOR SSA USE ONLY

TOE 250
FOR SSA USE ONLY

Name or
Bene. Sym.

Program

Date of
Birth

Type

Gdn.

Cus.

Inst.

Nam.

REQUEST TO BE
SELECTED AS
PAYEE

DISTRICT OFFICE CODE
STATE AND COUNTY
CODE

PRINT IN INK:
The name of the NUMBER HOLDER

SOCIAL SECURITY NUMBER

The name of the PERSON(S) (if different from above) for whom you are filing
(the "claimant(s)")

SOCIAL SECURITY NUMBER(S)

Answer item 1 ONLY if you are the claimant and want your benefits paid directly to you.
1.

I request that I be paid directly.
CHECK HERE

and answer only items 3, 5, 6, and 8 before signing the form on page 4.

I REQUEST THAT THE SOCIAL SECURITY, SUPPLEMENTAL SECURITY INCOME, OR SPECIAL VETERANS
BENEFITS FOR THE CLAIMANT(S) NAMED ABOVE BE PAID TO ME AS REPRESENTATIVE PAYEE.
2. Explain why you think the claimant is not able to handle his/her own benefits. (In your answer, describe how
he/she manages any money he/she receives now.)
Claimant is a minor child
3. Explain why you would be the best representative payee. (Use Remarks if you need more space.)
4. If you are appointed payee, how will you know about the claimant's needs?
Live with me or in the institution I represent
Daily visits
Visits at least once a week.
By other means. Explain:
5. Does the claimant have a court-appointed legal guardian/conservator?

YES

IF YES, enter the legal guardian/conservator's:
NAME
ADDRESS
PHONE NUMBER
TITLE
DATE OF APPOINTMENT
Explain the circumstances of the appointment. (Use remarks if you need more space.)

Form SSA-11-BK (01-2014) EF (01-2014)
Use (08-2009) EF (08-2009) edition until exhausted

Page 1

6. (a) Where does the claimant live?
Alone
In my home (Go to (b).)

In a public institution (Go to (c).)

With a relative (Go to (b).)
With someone else (Go to (b).)

In a private institution (Go to (c).)
In a nursing home (Go to (c).)

In a board and care facility (Go to (b).)

In the institution I represent (Go to (c).)

(b) Enter the names and relationships of any other people who live with the claimant.
NAME

RELATIONSHIP

Telephone Number:

(d) Do you expect the claimant's living arrangements to change in the next year?
YES
NO If YES, explain what changes are expected and when they will occur.
(Use Remarks if you need more space.)
7. If you are applying on behalf of minor child(ren) and you are not the parent,
YES
NO
Does the child(ren) have a living natural or adoptive parent?
If YES, enter:

(a) Name of parent
(b) Address of parent
(c) Telephone number
(d) Does the parent show interest in the child?
Please explain.

YES

8. List the names and relationship of any (other) relatives or close friends who have provided support and/or show
active interest with the claimant. Describe the type and amount of support and/or how interest is displayed.
NAME

ADDRESS/PHONE NO.

RELATIONSHIP

DESCRIBE

9. Check the block that describes your relationship to the claimant.
(a)

Official of bank, agency or institution with responsibility for the person. Enter below which you represent:
Bank
Social Agency
Public Official
Institution:
Federal
State/Local
Private non-profit
Private proprietary institution. Is the institution licensed under State law?

YES

IF (a) ABOVE CHECKED, COMPLETE ONLY QUESTIONS 10 AND 11 AND SIGN THE FORM ON PAGE 4.
(b)
Parent
(c)
(d)
(e)

Spouse
Other Relative - Specify
Legal Representative

(f)
Board and Care Home Operator
(g)
Other Individual - Specify
IF (b), (c), (d), or (e) ABOVE CHECKED, GO ON TO QUESTION 12
Form SSA-11-BK (01-2014) EF (01-2014)

Page 2

10. Does the claimant owe you/your organization any money now or will he/she owe you money in the future?
YES
NO
If YES, enter the amount he/she owes you/your organization, the date(s) was/will be incurred and describe why
the debt was/will be incurred.
INFORMATION ABOUT INSTITUTIONS, AGENCIES AND BANKS APPLYING TO BE REPRESENTATIVE PAYEE
11. (a) Enter the name of the institution
(b) Enter the EIN of the institution
INFORMATION ABOUT INDIVIDUALS APPLYING TO BE REPRESENTATIVE PAYEE
12. Enter: YOUR NAME
DATE OF BIRTH
SOCIAL SECURITY NUMBER
ANY OTHER NAME YOU HAVE USED
OTHER SSN'S YOU HAVE USED
13. How long have you known the claimant?
14. If the claimant lives with you, who takes care of the claimant when work or other activity takes you away from home?
What is his/her relationship to the claimant?
15. (a) Main source of your income
Employed (answer (b) below)
Self-employed (Type of Business

)

Social Security benefits (Claim Number

)

Pension (describe

)

Supplemental Security Income payments (Claim Number

)

AFDC (County & State

)

Other Welfare (describe

)

Other (describe

)

(b) Enter your employer's name and address:
How long have you been employed by this employer?
(If less than 1 year, enter name and address of previous employer in Remarks.)
16. (a) Have you ever been convicted of a felony?

YES

If YES: What was the crime?
On what date were you convicted?
What was your sentence?
If imprisoned, when were you released?
If probation was ordered, when did/will your probation end?
(b) Have you ever been convicted of any offense under federal or state law which resulted in imprisonment for
more than one year?

YES

Page 3

17. Do you have any unsatisfied FELONY warrants (or in jurisdictions that do not define crimes as felonies, a crime
punishable by death or imprisonment exceeding 1 year) for your arrest?
If YES: Date of Warrant
State where warrant was issued

YES

18. How long have you lived at your current address? (Give Date MM/YY)
REMARKS: (This space may be used for explaining any answers to the questions. If you need more space, attach a
separate sheet.)

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING THIS FORM
I/my organization:
• Must use all payments made to me/my organization as the representative payee for the claimant's current needs or (if
not currently needed) save them for his/her future needs.
• May be held liable for repayment if I/my organization misuse the payments or if I/my organization am/is at fault for any
overpayment of benefits.
• May be punished under Federal law by fine, imprisonment or both if I/my organization am/is found guilty of misuse of
Social Security or SSI benefits.
I/my organization will:
• Use the payments for the claimant's current needs and save any currently unneeded benefits for future use.
• File an accounting report on how the payments were used, and make all supporting records available for review if
requested by the Social Security Administration.
• Reimburse the amount of any loss suffered by any claimant due to misuse of Social Security or SSI funds by me/my
organization.
• Notify the Social Security Administration when the claimant dies, leaves my/my organization's custody or otherwise
changes his/her living arrangements or he/she is no longer my/my organization's responsibility.
• Comply with the conditions for reporting certain events (listed on the attached sheets(s) which I/my organization will
keep for my/my organization's records) and for returning checks the claimant is not due.
• File an annual report of earnings if required.
• Notify the Social Security Administration as soon as I/my organization can no longer act as representative payee or the
claimant no longer needs a payee.
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.
DATE (Month, day, year)
SIGNATURE OF APPLICANT
Signature (First name, middle initial, last name) (Write in ink)

Telephone number(s) at which you
may be contacted during the day

Print Your Name & Title (if a representative or employee of an institution/organization)
Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)
City and State

Zip Code

Name of County

Residence Address (Number and street, Apt. No., P.O. Box, or Rural Route)
City and State

Zip Code

Name of County

Witnesses are only required if this application has been signed by mark (X) above. If signed by mark (X), two witnesses
to the signing who know the applicant making the request must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS

2. SIGNATURE OF WITNESS

ADDRESS (Number and street, City, State and ZIP Code) ADDRESS (Number and street, City, State and ZIP Code)

Form SSA-11-BK (01-2014) EF (01-2014)

Page 4

SOCIAL SECURITY
Information for Representative Payees Who Recieve Social Security Benefits
YOU MUST NOTIFY THE SOCIAL SECURITY ADMINISTRATION PROMPTLY IF ANY OF THE FOLLOWING
EVENTS OCCUR AND PROMPTLY RETURN ANY PAYMENT TO WHICH THE CLAIMANT IS NOT ENTITLED:
• the claimant DIES (Social Security entitlement ends the month before the month the claimant dies);
• the claimant MARRIES, if the claimant is entitled to child's, widow's, mother's, father's, widower's or parent's benefits,
or to wife's or husband's benefits as divorced wife/husband, or to special age 72 payments;
• the claimant's marriage ends in DIVORCE or ANNULMENT, if the claimant is entitled to wife's, husband's or special
age 72 payments;
• the claimant's SCHOOL ATTENDANCE CHANGES if the claimant is age 18 or over and entitled to child's benefits
as a full time student
• the claimant is entitled as a stepchild and the parents DIVORCE (benefits terminate the month after the month the
divorce becomes final);
• the claimant is under FULL RETIREMENT AGE (FRA) and WORKS for more than the annual limit (as determined
each year) or more than the allowable time (for work outside the United States);
• the claimant receives a GOVERNMENT PENSION or ANNUITY or the amount of the annuity changes, if the
claimant is entitled to husband's, widower's, or divorced spouse's benefit's;
• the claimant leaves your custody or care or otherwise CHANGES ADDRESS;
• the claimant NO LONGER HAS A CHILD IN CARE, if he/she is entitled to benefits because of caring for a child
under age 16 or who is disabled;
• the claimant is confined to jail, prison, penal institution or correctional facility;
• the claimant is confined to a public institution by court order in connection WITH A CRIME.
• the claimant has an UNSATISFIED FELONY WARRANT (or in jurisdictions that do not define crimes as felonies, a
crime punishable by death or imprisonment exceeding 1 year) issue for his/her arrest;
• the claimant is violating a condition of probation or parole under State or Federal law.
IF THE CLAIMANT IS RECEIVING DISABILITY BENEFITS, YOU MUST ALSO REPORT IF:
• the claimant's MEDICAL CONDITION IMPROVES;
• the claimant STARTS WORKING;
• the claimant applies for or receives WORKER'S COMPENSATION BENEFITS, Black Lung Benefits from the
Department of Labor, or a public disability benefit;
• the claimant is DISCHARGED FROM THE HOSPITAL (if now hospitalized).
IF THE CLAIMAINT IS RECEIVING SPECIAL AGE 72 PAYMENTS, YOU MUST ALSO REPORT IF:
• the claimant or spouse becomes ELIGIBLE FOR PERIODIC GOVERNMENTAL PAYMENTS, whether from the
U.S. Federal government or from any State or local government;
• the claimant or spouse receives SUPPLEMENTAL SECURITY INCOME or PUBLIC ASSISTANCE CASH
BENEFITS;
• the claimant or spouse MOVES outside the United States (the 50 States, the District of Columbia and the Northern
Marian Islands).
In addition to these events about the claimant, you must also notify us if:
• YOU change your address;
• YOU are convicted of a felony or any offense under State or Federal law which results in imprisonment for more
than 1 year;
• YOU have a UNSATISFIED FELONY WARRANT (or in jurisdictions that do not define crimes as felonies, a crime
punishable by death or imprisonment exceeding 1 year) issued for your arrest.
BENEFITS MAY STOP IF ANY OF THE ABOVE EVENTS OCCUR. You should read the informational booklet we will
send you to see how these events affect benefits. You may make your reports by telephone, mail, or in person.
REMEMBER:
• payments must be used for the claimant's current needs or saved if not currently needed;
• you may be held liable for repayment of any payments not used for the claimant's needs or of any over
payment that occured due to your fault;
• you must account for benefits when so asked by the Social Security Administration. You will keep records
of how benefits were spent so you can provide us with correct accounting;
• to tell us as soon as you know you will no longer be able to act as representative payee or the claimant no
longer needs a payee.
Keep in mind that benefits may be deposited directly into an account set up for the claimant with you as payee.
As soon as you set up such an account, contact us for more information about receiving the claimant's
payments using direct deposit.
Form SSA-11-BK (01-2014) EF (01-2014)

Page 5

A REMINDER TO PAYEE APPLICANTS
TELEPHONE
NUMBER(S) TO
CALL IF YOU HAVE
A QUESTION OR
SOMETHING TO
REPORT

BEFORE YOU RECEIVE A
DECISION NOTICE

SSA OFFICE

DATE REQUEST RECEIVED

AFTER YOU RECEIVE A
DECISION NOTICE

RECEIPT FOR YOUR REQUEST
you - or someone for you - should report the change.
Your request for Social Security benefits on behalf of
The changes to be reported are listed on the reverse.
the individual(s) named below has been received and
will be processed as quickly as possible.
Always give us the claim number of the beneficiary
when writing or telephoning about the claim.
You should hear from us within
days after you
have given us all the information we requested. Some
If you have any questions about this application, we will
claims may take longer if additional information is
be glad to help you.
needed.
In the meantime, if you change your address, or if there
is some other change that may affect the benefits
payable,
BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER

Privacy Act Statement - Collection and Use of Personal Information
Sections 205(a) and 205(j) of the Social Security Act, as amended, authorize us to collect this information. We will use
the information you provide to determine if you are qualified to serve as a representative payee. Furnishing us this
information is voluntary. However, failing to provide all or part of the information could prevent us from making a
determination to select you as a representative payee.
We rarely use the information you supply for any purpose other than for determining continuing eligibility. However, we
may use it for the administration and integrity of our 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. To
enable a third party or an agency to assist us in establishing rights to our benefits and coverage; 2. To comply with
Federal laws requiring the release of information from our records (e.g., to the Government Accountability Office and
Department of Veterans Affairs); 3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and, 4. To facilitate statistical research, audit, or investigative activities
necessary to assure the integrity and improvement of our programs. (e.g., to the Bureau of Census and to private
entities under contract with us).
We may also use the information you provide 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 matching
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 Systems of Records Notice entitled,
Master Representative Payee File, 60-0222. Additional information regarding these and other systems of records
notices are available on-line at www.socialsecurity.gov or at 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 (OMB) control number. We estimate that it will take about 11 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 21235-0001.
Form SSA-11-BK (01-2014) EF (01-2014)

Page 6

SUPPLEMENTAL SECURITY INCOME
Information for Representative Payees Who Receive Social Security Benefits
YOU MUST NOTIFY THE SOCIAL SECURITY ADMINISTRATION PROMPTLY IF ANY OF THE FOLLOWING
EVENTS OCCUR AND PROMPTLY RETURN ANY PAYMENT TO WHICH THE CLAIMANT IS NOT ENTITLED:
• the claimant or any member of the claimant's household DIES (SSI eligibility ends with the month in which the
claimant dies);
• the claimant's HOUSEHOLD CHANGES (someone moves in/out of the place where the claimant lives);
• the claimant LEAVES THE U.S. (the 50 states, the District of Columbia, and the Northern Mariana Islands) for 30
consecutive days or more;
• the claimant MOVES or otherwise changes the place where he/she actually lives (including adoption, and
whereabouts unknown);
• the claimant is ADMITTED TO A HOSPITAL, skilled nursing facility, nursing home, intermediate care facility, or
other institution;
• the INCOME of the claimant or anyone in the claimant's household CHANGES (this includes income paid by an
organization or employer, as well as monetary benefits from other sources);
• the RESOURCES of the claimant or anyone in the claimant's household CHANGES (this includes when conserved
funds reach over $2,000);
• the claimant or anyone in the claimant's household MARRIES;
• the marriage of the claimant or anyone in the claimant's household ends in DIVORCE or ANNULMENT;
• the claimant SEPARATES from his/her spouse;
• the claimant is confined to jail, prison, penal institution or correctional facility;
• the claimant is confined to a public institution by court order in connection WITH A CRIME;
• the claimant has an UNSATISFIED FELONY WARRANT (or in jurisdictions that do not define crimes as felonies, a
crime punishable by death or imprisonment exceeding 1 year) issued for his/her arrest;
• the claimant is violating a condition of probation or parole under State or Federal law.
IF THE CLAIMANT IS RECEIVING PAYMENTS DUE TO DISABILITY OR BLINDNESS, YOU MUST ALSO
REPORT IF:
• the claimant's MEDICAL CONDITION IMPROVES;
• the claimant GOES TO WORK;
• the claimant's VISION IMPROVES, if the claimant is entitled due to blindness;
In addition to these events about the claimant, you must also notify us if:
• YOU change your address;
• YOU are convicted of a felony or any offense under State or Federal law which results in imprisonment for more
than 1 year;
• YOU have an UNSATISFIED FELONY WARRANT (or in jurisdictions that do not define crimes as felonies, a crime
punishable by death or imprisonment exceeding 1 year) issued for your arrest.
PAYMENT MAY STOP IF ANY OF THE ABOVE EVENTS OCCUR. You should read the informational booklet we will
send you to see how these events affect benefits. You may make your reports by telephone, mail or in person.
REMEMBER :
• payments must be used for the claimant's current needs or saved if not currently needed. (Savings are considered
resources and may affect the claimant's eligibility to payment.);
• you may be held liable for repayment of any payments not used for the claimant's needs or of any overpayment that
occurred due to your fault;
• you must account for benefits when so asked by the Social Security Administration. You will keep records of how
benefits were spent so you can provide us with a correct accounting;
• to let us know as soon as you know you are unable to continue as representative payee or the claimant no longer
needs a payee
• you will be asked to help in periodically redetermining the claimant's continued eligibility or payment. You will need
to keep evidence to help us with the redetermination (e.g., evidence of income and living arrangements).
• you may be required to obtain medical treatment for the claimant's disabling condition if he/she is eligible under the
childhood disability provision.
Keep in mind that payments may be deposited directly into an account set up for the claimant with you as payee. As
soon as you set up such an account, contact us for more information about receiving the claimant's payments using
direct deposit.
Form SSA-11-BK (01-2014) EF (01-2014)

Page 7

A REMINDER TO PAYEE APPLICANTS
TELEPHONE
NUMBER(S) TO
CALL IF YOU HAVE
A QUESTION OR
SOMETHING TO
REPORT

BEFORE YOU RECEIVE A
DECISION NOTICE

SSA OFFICE

DATE REQUEST RECEIVED

AFTER YOU RECEIVE A
DECISION NOTICE

RECEIPT FOR YOUR REQUEST
Your request for SSI payments on behalf of the
you - or someone for you - should report the change.
individual(s) named below has been received and will
The changes to be reported are listed on the reverse.
be processed as quickly as possible.
Always give us the claim number of the beneficiary
You should hear from us within
days after you
when writing or telephoning about the claim.
have given us all the information we requested. Some
claims may take longer if additional information is
If you have any questions about this application, we will
needed.
be glad to help you.
In the meantime, if you change your address, or if there
is some other change that may affect the benefits
payable,
BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER

Page 8

SPECIAL BENEFITS FOR WORLD WAR II VETERANS
Information for Representative Payees Who Receive Special Benefits for WW II Veterans
YOU MUST NOTIFY THE SOCIAL SECURITY ADMINISTRATION PROMPTLY IF ANY OF THE FOLLOWING
EVENTS OCCUR AND PROMPTLY RETURN ANY PAYMENT TO WHICH THE CLAIMANT IS NOT ENTITLED:
• the claimant DIES (special veterans entitlement ends the month after the claimant dies);
• the claimant returns to the United States for a calendar month or longer;
• the claimant moves or changes the place where he/she actually lives;
• the claimant receives a pension, annuity or other recurring payment (includes workers' compensation, veterans
benefits or disability benefits), or the amount of the annuity changes;
• the claimant is or has been deported or removed from U.S.;
• the claimant has an UNSATISFIED FELONY WARRANT (or in jurisdictions that do not define crimes as felonies, a
crime punishable by death or imprisonment exceeding 1 year) issued for his/her arrest;
• the claimant is violating a condition of probation or parole under State or Federal law.
In addition to these events about the claimant, you must also notify us if:
• YOU change your address;
• YOU are convicted of a felony or any offense under State or Federal law which results in imprisonment for more
than 1 year;
• YOU have an UNSATISFIED FELONY WARRANT (or in jurisdictions that do not define crimes as felonies, a crime
punishable by death or imprisonment exceeding 1 year) issued for your arrest.
BENEFITS MAY STOP IF ANY OF THE ABOVE EVENTS OCCUR. You can make your reports by telephone, mail or in
person. You can contact any U.S. Embassy, Consulate, Veterans Affairs Regional Office in the Philippines or any U.S.
Social Security Office.

REMEMBER:
• payments must be used for the claimant's current needs or saved if not currently needed;
• you may be held liable for repayment of any payments not used for the claimant's needs or of any overpayment that
occurred due to your fault;
• you must account for benefits when so asked by the Social Security Administration. You will keep records of how
benefits were spent so you can provide us with a correct accounting;
• to let us know, as soon as you know you are unable to continue as representative payee or the claimant no longer
needs a payee.

Form SSA-11-BK (01-2014) EF (01-2014)

Page 9

A REMINDER TO PAYEE APPLICANTS
TELEPHONE
NUMBER(S) TO
CALL IF YOU HAVE
A QUESTION OR
SOMETHING TO
REPORT

BEFORE YOU RECEIVE A
DECISION NOTICE

SSA OFFICE

DATE REQUEST RECEIVED

AFTER YOU RECEIVE A
DECISION NOTICE

RECEIPT FOR YOUR REQUEST
Your request for Special benefits for WW II Veterans on
you - or someone for you - should report the change.
behalf of the individual(s) named below has been
The changes to be reported are listed on the reverse.
received and will be processed as quickly as possible.
Always give us the claim number of the beneficiary
You should hear from us within
days after you
when writing or telephoning about the claim.
have given us all the information we requested. Some
claims may take longer if additional information is
If you have any questions about this application, we will
needed.
be glad to help you.
In the meantime, if you change your address, or if there
is some other change that may affect the benefits
payable,
BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER

Page 10

File Type	application/pdf
File Title	REQUEST TO BE SELECTED AS PAYEE
Subject	SSA-11, SSA-11-BK, request, payee, payments
Author	SSA
File Modified	2014-01-31
File Created	2009-10-29