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The SSA-11 form, officially known as the "Request to be Selected as Payee," plays a crucial role in the Social Security Administration's efforts to ensure that benefits are managed responsibly for those who cannot handle their own financial affairs. This form is primarily used when an individual, referred to as the "representative payee," seeks to receive Social Security, Supplemental Security Income (SSI), or special veterans' benefits on behalf of another person, known as the "claimant." It requires detailed information about both the claimant and the proposed payee, including the claimant's living situation, any existing legal guardianship, and the payee's relationship to the claimant. The form also prompts the applicant to explain why they believe the claimant is unable to manage their benefits independently and why they would be the best choice as a representative payee. Additionally, it covers the payee's financial background, including their income sources and any potential conflicts of interest. By filling out this form, applicants commit to using the benefits solely for the claimant's needs and must agree to comply with various reporting requirements to maintain transparency and accountability. Understanding the nuances of the SSA-11 form is essential for anyone looking to navigate the complexities of Social Security benefits on behalf of another individual.

Sample - Ssa 11 Form

Form SSA-11-BK (09-2020) UF

 

 

 

 

 

 

Discontinue Prior Editions

 

 

 

 

 

Page 1 of 11

Social Security Administration

 

 

 

 

 

OMB No. 0960-0014

 

 

 

FOR SSA USE ONLY

 

 

FOR SSA USE ONLY

 

 

 

 

 

 

 

 

 

Name or

Program

Date of

Type Gdn. Cus.

Inst. Nam.

 

Request to be

Bene. Sym.

Birth

 

 

 

 

 

 

 

 

Selected as

 

 

 

 

 

 

 

Payee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

District Office Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Print in Ink

 

 

 

 

 

 

State and County Code

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

SOCIAL SECURITY NUMBER (S)

"claimant(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 5.

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

No

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 (09-2020) UF

Page 2 of 11

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).)

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

 

With someone else (Go to (b).)

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

 

 

 

 

 

 

 

 

 

 

 

 

(c) Enter the claimant's residence and mailing addresses (if different from yours).

Residence:

Mailing:

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,

 

Is the child(ren) in foster care?

Yes

No

Does the child(ren) have a living natural or adoptive parent?

Yes

No

If yes, enter: (a) Name of parent

 

 

 

(b) Address of parent

 

 

(c) Telephone number

 

 

 

(d) Does the parent show interest in the child?

Yes

No

Please explain:

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form SSA-11-BK (09-2020) UF

Page 3 of 11

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

State, county, or local government agency

Social Agency

Public Official

Institution:

 

 

 

 

Federal

State/Local

Private non-profit

 

 

Private proprietary institution. Is the institution licensed under State law?

Yes

No

IF (a) ABOVE CHECKED, COMPLETE ONLY QUESTIONS 10 AND 11 AND SIGN THE FORM ON PAGE 5.

(b) Parent

(c) Spouse

(d) Other Relative - Specify

(e) 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

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

 

)

Temporary Assistance For Needy Families (TANF

 

)

Other State or Public Assistance (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.)

Form SSA-11-BK (09-2020) UF

Page 4 of 11

16.

Do you give Social Security permission to conduct a criminal background check on you?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17.

(a) Have you ever been convicted of a felony?

Yes

No

 

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

Yes

No

 

for more than one year?

 

 

 

 

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?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.

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?

Yes

No

 

If Yes: Date of Warrant

 

 

 

 

 

State where warrant was issued

 

 

 

 

 

 

 

 

 

19.

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.)

Form SSA-11-BK (09-2020) UF

Page 5 of 11

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.

SIGNATURE OF APPLICANT

Signature (First name, middle initial, last name) (Write in ink)

DATE (MM/DD/YYYY)

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 (09-2020) UF

Page 6 of 11

SOCIAL SECURITY

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 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 Mariana 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 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 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 (09-2020) UF

 

 

Page 7 of 11

 

 

A REMINDER TO PAYEE APPLICANTS

 

 

 

 

 

 

Telephone

Before you Receive a

 

SSA Office

Date Request

Decision Notice

 

 

Received

Number(s) to Call

 

 

if you have a

 

 

 

 

Question or

After you Receive a

 

 

 

Something to

Decision Notice

 

 

 

Report

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECEIPT FOR YOUR REQUEST

 

Your request for Social Security benefits on behalf of the individual(s) named below has been received and will be processed as quickly as possible.

You should hear from us within days after you have given us all the information we requested. Some claims may take longer if additional information is needed.

In the meantime, if you change your address, or if there is some other change that may affect the benefits payable,

you - or someone for you - should report the change. The changes to be reported are listed on the reverse.

Always give us the claim number of the beneficiary when writing or telephoning about the claim.

If you have any questions about this application, we will be glad to help you.

BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER

Privacy Act Statement

Collection and Use of Personal Information

Sections 205(a), 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 prevent an accurate and timely decision on your request for selection as a representative payee.

We will use the information to determine your eligibility to serve as a representative payee. We may also share your information for the following purposes, called routine uses:

•To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA) in the efficient administration of its programs;

•To agencies or entities who have a written agreement with SSA, to perform reviews of the representative payee program and to provide training, administrative oversight, technical assistance, and other support for the program review; and

•To third parties, contractors, or other Federal agencies, as necessary, to conduct criminal background checks and to obtain criminal history information on representative payees and representative payee applicants.

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's 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 Notices (SORN) 60-0089 entitled Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784; 60-0222, entitled Master Representative Payee File, as published in the FR on November 2, 2018, at 83 FR 55228; and 60-0320, entitled Electronic Disability Claim File, as published in the FR on December 22, 2003, at 68 FR 71210. Additional information, and a full listing of all our SORNs, is available on our website at www.ssa.gov/privacy.

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 21235-6401.

Form SSA-11-BK (09-2020) UF

Page 8 of 11

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 (09-2020) UF

 

 

Page 9 of 11

 

 

A REMINDER TO PAYEE APPLICANTS

 

 

 

 

 

 

Telephone

Before you Receive a

 

SSA Office

Date Request

Decision Notice

 

 

Received

Number(s) to Call

 

 

if you have a

 

 

 

 

Question or

After you Receive a

 

 

 

Something to

Decision Notice

 

 

 

Report

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECEIPT FOR YOUR REQUEST

 

Your request for SSI payments on behalf of the individual(s) named below has been received and will be processed as quickly as possible.

You should hear from us within days after you have given us all the information we requested. Some claims may take longer if additional information is needed.

In the meantime, if you change your address, or if there is some other change that may affect the benefits payable,

you - or someone for you - should report the change. The changes to be reported are listed on the reverse.

Always give us the claim number of the beneficiary when writing or telephoning about the claim.

If you have any questions about this application, we will be glad to help you.

BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER

Privacy Act Statement

Collection and Use of Personal Information

Sections 205(a), 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 prevent an accurate and timely decision on your request for selection as a representative payee.

We will use the information to determine your eligibility to serve as a representative payee. We may also share your information for the following purposes, called routine uses:

•To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA) in the efficient administration of its programs;

•To agencies or entities who have a written agreement with SSA, to perform reviews of the representative payee program and to provide training, administrative oversight, technical assistance, and other support for the program review; and

•To third parties, contractors, or other Federal agencies, as necessary, to conduct criminal background checks and to obtain criminal history information on representative payees and representative payee applicants.

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's 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 Notices (SORN) 60-0089 entitled Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784; 60-0222, entitled Master Representative Payee File, as published in the FR on November 2, 2018, at 83 FR 55228; and 60-0320, entitled Electronic Disability Claim File, as published in the FR on December 22, 2003, at 68 FR 71210. Additional information, and a full listing of all our SORNs, is available on our website at www.ssa.gov/privacy.

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 21235-6401.

Form SSA-11-BK (09-2020) UF

Page 10 of 11

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.

File Specs

Fact Name Details
Form Purpose The SSA-11 form is used to request that Social Security benefits be paid to a representative payee on behalf of a claimant who cannot manage their benefits.
Eligibility Individuals applying to be a payee must demonstrate that the claimant is unable to manage their own benefits due to various reasons, such as age or disability.
Required Information Applicants must provide personal details, including their relationship to the claimant, the claimant's living situation, and any existing legal guardianship.
Governing Laws This form is governed by federal regulations under the Social Security Act, which outlines the responsibilities of representative payees.
Reporting Requirements Payees must report significant changes in the claimant's circumstances, such as changes in living arrangements or if the claimant passes away.
Filing Process The completed form must be submitted to the local Social Security Administration office for processing. It is advisable to keep a copy for personal records.
Annual Reporting Representative payees may be required to file an annual report detailing how the benefits were used for the claimant's needs.

Ssa 11 - Usage Guidelines

Filling out the SSA-11 form is a straightforward process that requires careful attention to detail. After completing the form, it should be submitted to the Social Security Administration for processing. Be sure to provide accurate information to avoid any delays in your application.

  1. Obtain the SSA-11 form. You can download it from the Social Security Administration's website or request a paper form by contacting them directly.
  2. Fill in your personal information. This includes your name, date of birth, and Social Security number. Be sure to print clearly in ink.
  3. Provide the claimant's information. Enter the name and Social Security number of the person for whom you are filing.
  4. Indicate your request for direct payment. If you are the claimant and want benefits paid directly to you, check the appropriate box and answer items 3, 5, 6, and 8.
  5. Explain the claimant's situation. In item 2, describe why you believe the claimant cannot handle their own benefits.
  6. State your qualifications. In item 3, explain why you would be the best representative payee.
  7. Detail how you will know about the claimant's needs. Answer item 4 by selecting the appropriate option and providing any necessary explanations.
  8. Address any legal guardianship. If applicable, answer item 5 with the guardian's information.
  9. Describe the claimant's living situation. Complete item 6 by indicating where the claimant lives and providing additional details as needed.
  10. Provide information about any parents. If you are applying on behalf of a minor child, answer item 7 regarding the child's parents.
  11. List supportive individuals. In item 8, provide names and relationships of people who support the claimant.
  12. Identify your relationship to the claimant. In item 9, check the box that best describes your relationship.
  13. Disclose any debts. If the claimant owes you money, answer item 10 with the necessary details.
  14. Fill in your personal details. In item 12, provide your name, date of birth, Social Security number, and any other names you have used.
  15. Answer questions about your relationship with the claimant. Complete items 13 to 19 as applicable.
  16. Sign the form. Ensure your signature is clear and dated. If necessary, include witness signatures.

Your Questions, Answered

What is the SSA-11 form used for?

The SSA-11 form, also known as the Request to be Selected as Payee, is utilized when an individual wishes to become a representative payee for someone receiving Social Security benefits. This form allows a person to manage the benefits on behalf of another individual, known as the claimant, who may be unable to handle their own financial matters due to various reasons, such as age or disability.

Who can apply to be a representative payee?

Any responsible adult can apply to be a representative payee. This includes parents, legal guardians, relatives, or even professionals from institutions or agencies that provide care. The applicant must demonstrate their ability to manage the claimant's benefits responsibly and ensure that the funds are used for the claimant's current needs.

What information is required to complete the SSA-11 form?

To complete the SSA-11 form, the applicant must provide detailed information about themselves and the claimant. This includes names, Social Security numbers, living arrangements, and any relevant relationships. Additionally, the applicant must explain why they believe the claimant cannot manage their benefits and how they intend to fulfill their responsibilities as a payee.

What responsibilities does a representative payee have?

A representative payee is responsible for using the benefits received for the claimant's current needs or saving them for future use. They must keep accurate records of all transactions and be prepared to report on how the funds are spent. Furthermore, the payee must notify the Social Security Administration of any changes in the claimant's circumstances, such as changes in address or if the claimant passes away.

How does one report changes in the claimant's situation?

Changes in the claimant's situation should be reported to the Social Security Administration promptly. This can be done through telephone, mail, or in person. It is crucial to inform them of significant events such as the claimant's death, change of address, or any changes in their ability to manage their benefits.

What happens if a representative payee misuses the funds?

If a representative payee misuses the funds, they may be held liable for repayment of any misused payments. Misuse can include failing to use the funds for the claimant's needs or causing overpayments. Legal consequences may also arise, including fines or imprisonment, depending on the severity of the misuse.

Is there a specific way to submit the SSA-11 form?

The completed SSA-11 form should be submitted to the Social Security Administration. It is important to ensure that all sections are filled out accurately and completely to avoid delays in processing. The form can typically be submitted in person at a local Social Security office or by mail, depending on the instructions provided by the SSA.

Common mistakes

  1. Incomplete Information: Many individuals fail to fill out all required fields. Omitting essential details can delay the processing of the application.

  2. Incorrect Social Security Numbers: Entering the wrong Social Security number for either the claimant or the payee can lead to significant complications. Always double-check this information.

  3. Failure to Explain Circumstances: Not providing sufficient details on why the claimant cannot manage their benefits can result in denial of the request. Clear and thorough explanations are crucial.

  4. Not Including Supporting Documentation: Some applicants neglect to attach necessary documents that support their claims. This can hinder the approval process.

  5. Ignoring Signature Requirements: Failing to sign the form or not having the necessary witnesses can invalidate the application. Ensure that all signatures are in place before submission.

  6. Inadequate Follow-Up: After submitting the form, some individuals do not follow up with the Social Security Administration. Staying informed about the status of your application is important.

Documents used along the form

When applying to be a representative payee using the SSA-11 form, it is often necessary to submit additional documentation to support your application. These documents provide crucial information about the claimant and the payee's relationship, ensuring that the Social Security Administration (SSA) can make informed decisions. Below is a list of common forms and documents that may accompany the SSA-11 form.

  • Form SSA-827: This form is a medical release that allows the SSA to obtain necessary medical records and information about the claimant's condition. It is essential for assessing the claimant's eligibility for benefits, especially if they are unable to manage their affairs due to a medical condition.
  • Form SSA-3373: This form is used to gather detailed information about the claimant's daily activities and functional capabilities. It helps the SSA understand how the claimant's limitations affect their ability to manage their benefits and daily life.
  • Proof of Identity: A copy of the payee's identification, such as a driver's license or passport, is typically required. This document verifies the identity of the individual applying to be the representative payee and ensures that the SSA is dealing with the correct person.
  • Proof of Relationship: Documentation that establishes the relationship between the claimant and the proposed payee may be necessary. This could include birth certificates, marriage certificates, or legal guardianship papers, depending on the situation.
  • Financial Statements: Recent bank statements or proof of income may be required to demonstrate the payee's financial stability. This information helps the SSA assess whether the payee can responsibly manage the claimant's benefits.

Submitting these additional forms and documents alongside the SSA-11 can streamline the application process and help the SSA better understand the claimant's needs. Being thorough and providing complete information will facilitate a smoother review, ultimately benefiting both the claimant and the proposed payee.

Similar forms

The SSA-11 form is similar to the VA Form 21-0845, which is used by individuals to designate someone to act on their behalf regarding VA benefits. Both forms require the individual to explain why they cannot manage their benefits independently. The VA form also asks for information about the representative’s relationship to the claimant, ensuring that the designated individual is capable of handling the claimant’s financial matters responsibly.

Another document akin to the SSA-11 is the IRS Form 2848, which grants power of attorney to someone for tax matters. Like the SSA-11, this form requires personal information about both the taxpayer and the representative. It also includes a section where the taxpayer must explain why they are unable to manage their tax affairs, similar to the SSA-11’s request for justification of the need for a representative payee.

The Medicaid Application form shares similarities with the SSA-11 in that both require detailed information about the claimant’s living situation and financial status. The Medicaid form also asks for information about any guardianship or conservatorship arrangements, paralleling the SSA-11’s inquiry into the claimant's ability to manage their benefits. Both documents aim to ensure that the claimant receives the appropriate support based on their needs.

Form 4506-T, the Request for Transcript of Tax Return, is another related document. This form allows individuals to authorize someone else to request their tax return information. Similar to the SSA-11, it includes sections for identifying the taxpayer and the representative, as well as a declaration that the taxpayer is unable to manage certain aspects of their financial affairs independently.

The Durable Power of Attorney form also bears resemblance to the SSA-11. This document allows an individual to appoint someone to make financial decisions on their behalf if they become incapacitated. Both forms require a clear explanation of the relationship between the individual and the representative, emphasizing the importance of trust and responsibility in managing someone else's financial matters.

Form SSA-16, the Application for Disability Insurance Benefits, is similar in that it also requires a detailed explanation of the claimant's inability to work due to medical conditions. While the SSA-11 focuses on the need for a representative payee, the SSA-16 centers on qualifying for benefits, yet both forms necessitate a thorough understanding of the claimant's circumstances and needs.

The Social Security Administration’s Direct Deposit Enrollment form is another document that shares commonalities with the SSA-11. Both forms aim to facilitate the efficient management of benefits. The Direct Deposit form requires information about the claimant’s banking details and their representative's relationship to them, ensuring that funds are managed appropriately and securely.

Form 21-526EZ, the Application for Disability Compensation and Related Compensation Benefits, is akin to the SSA-11 in that it helps individuals apply for benefits due to incapacity. Both forms require personal details and explanations of the claimant's situation, aiming to ensure that individuals receive the support they need during challenging times.

Lastly, the Social Security Administration’s Representative Payee Report is similar in that it requires ongoing reporting of how benefits are used by the payee. This document ensures accountability and transparency, similar to the SSA-11’s requirements for the payee to manage the claimant’s funds responsibly and report any changes in circumstances.

Dos and Don'ts

When filling out the SSA-11 form, it's essential to follow certain guidelines to ensure your application is processed smoothly. Here’s a list of things you should and shouldn't do:

  • Do read the entire form carefully before starting to fill it out.
  • Do use black or blue ink to fill out the form.
  • Do provide accurate information about the claimant and yourself.
  • Do explain clearly why the claimant needs a representative payee.
  • Do include all necessary signatures where required.
  • Don't leave any sections blank unless instructed to do so.
  • Don't provide false information; this could lead to serious consequences.
  • Don't forget to check for any additional documents that may be required.
  • Don't rush through the application; take your time to ensure accuracy.
  • Don't hesitate to ask for help if you're unsure about any part of the form.

By following these tips, you can help ensure that your application is complete and accurate, which can make the process smoother for everyone involved.

Misconceptions

Misconceptions about the SSA-11 form can lead to confusion and errors in the application process. Here are eight common misconceptions, along with clarifications:

  • Only family members can be representative payees. Many individuals believe that only relatives can serve as payees. In reality, non-family members, such as friends or professionals, can also be appointed if they meet certain criteria.
  • The form is only for minors. While the SSA-11 form is often used for minor children, it is also applicable for adults who are unable to manage their benefits due to various reasons, including disability.
  • Once a payee is appointed, they cannot be changed. This is incorrect. A representative payee can be changed if circumstances change or if the payee is not fulfilling their responsibilities effectively.
  • Payees can use benefits for personal expenses. Benefits received by a representative payee must be used solely for the claimant's needs. Misuse of funds can lead to legal consequences.
  • The SSA-11 form is the only required document. Some individuals think that completing the SSA-11 form is sufficient. However, additional documentation may be required depending on the claimant's situation.
  • There is no oversight of representative payees. In fact, the Social Security Administration regularly reviews the activities of payees to ensure compliance with their responsibilities.
  • All payees receive the same amount of compensation. Compensation for payees is not uniform. It varies based on the specific circumstances and needs of the claimant.
  • Filling out the form is a quick process. Many believe that completing the SSA-11 form is straightforward and fast. In reality, it requires careful consideration and detailed information about the claimant's needs and circumstances.

Key takeaways

When filling out and using the SSA-11 form, here are some key takeaways to keep in mind:

  • Understand the Purpose: The SSA-11 form is used to request to be appointed as a representative payee for someone who cannot manage their Social Security benefits.
  • Identify the Claimant: Clearly state the name and Social Security number of the claimant, as well as your relationship to them.
  • Direct Payment Request: If you are the claimant and wish to receive benefits directly, check the appropriate box and complete only specific sections of the form.
  • Explain the Need: Provide detailed reasons why the claimant cannot handle their own benefits. This could include their age, mental capacity, or other circumstances.
  • Provide Your Qualifications: Describe why you would be the best representative payee. Highlight any relevant experience or relationship to the claimant.
  • Living Arrangements Matter: Indicate where the claimant lives and who else resides with them. This information helps the Social Security Administration understand the claimant's environment.
  • Report Changes Promptly: Notify the Social Security Administration immediately if there are any changes in the claimant’s situation, such as death, change of address, or change in living arrangements.
  • Accountability: As a payee, you are responsible for using the benefits for the claimant's current needs and keeping accurate records of how the funds are spent.
  • Legal Obligations: Be aware that misuse of benefits can lead to legal consequences, including fines or imprisonment.
  • Annual Reporting: You may be required to file an annual report on how the benefits were used, so keep thorough documentation.

By keeping these points in mind, you can ensure that the process of filling out and using the SSA-11 form goes smoothly and that the needs of the claimant are met effectively.