Representative Payee Application and Administration Guide

REPRESENTATIVE PAYEE APPLICATION AND ADMINISTRATION GUIDE

SSA FORM SSA-11-BK PREPARATION, PAYEE DUTIES, AND COMPLIANCE

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FEDERAL PROGRAM NOTICE: The Social Security Administration (SSA) Representative Payee Program is governed exclusively by federal law under Title II (42 U.S.C. § 405(j)), Title XVI (42 U.S.C. § 1383(a)(2)), and Title VIII (42 U.S.C. § 1007) of the Social Security Act and implementing regulations at 20 CFR Parts 404, 408, and 416. SSA does not recognize powers of attorney, state court appointments, or other state-law instruments as authorization to receive Social Security or SSI benefits on behalf of another person. Only a formally appointed representative payee may receive and manage benefits.

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TABLE OF CONTENTS

1. Overview and Legal Framework
2. Beneficiary Information Worksheet
3. Proposed Payee Information Worksheet
4. SSA Form SSA-11-BK Preparation Guide
5. Payee Selection Criteria and Preference Order
6. Disqualification Grounds
7. Advance Designation of Representative Payees
8. Application Process and Interview
9. Required Documentation Checklist
10. Representative Payee Duties and Responsibilities
11. Financial Management Requirements
12. Annual Accounting and Reporting
13. Dedicated Accounts for SSI Minors
14. Monthly Benefit Tracking Worksheet
15. Annual Summary Worksheet
16. Changes in Circumstances Reporting
17. Misuse, Penalties, and Liability
18. Challenging or Changing a Payee
19. Organizational Representative Payees
20. Payee Responsibility Acknowledgment
21. Important Contacts and Resources
22. Sources and References

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PART 1: OVERVIEW AND LEGAL FRAMEWORK

1.1 What Is a Representative Payee?

A representative payee is an individual or organization appointed by the Social Security Administration to receive and manage Social Security benefits (Title II), Supplemental Security Income (Title XVI/SSI), or Special Veterans Benefits (Title VIII/SVB) on behalf of a beneficiary whom SSA has determined cannot manage or direct the management of their own benefits. See 20 CFR § 404.2001; 20 CFR § 416.601.

1.2 When SSA Requires a Representative Payee

Under 42 U.S.C. § 405(j)(1)(A), SSA will appoint a representative payee when it determines that the interest of the beneficiary would be served thereby. SSA must appoint a representative payee in the following circumstances:

Circumstance	Statutory/Regulatory Basis
Minor children under age 18 (with limited exceptions)	20 CFR § 404.2010(b)
Adults adjudicated legally incompetent by a court	20 CFR § 404.2010(a); 42 U.S.C. § 405(j)(1)(A)
Adults SSA determines are unable to manage benefits	20 CFR § 404.2010(a)
Beneficiaries with drug addiction or alcoholism (DA&A) as a contributing factor to disability	42 U.S.C. § 405(j)(1)(B)

1.3 Factors SSA Considers in Determining Incapability

SSA evaluates the following evidence when determining whether a beneficiary needs a representative payee (20 CFR § 404.2011):

☐ Medical evidence of mental or physical incapability

☐ Court order of legal incompetence or guardianship

☐ Opinions of treating physicians or psychologists

☐ Observations by SSA field office personnel during face-to-face contact

☐ Statements from relatives, friends, or other concerned parties

☐ History of financial mismanagement or exploitation

☐ Evidence of substance use disorder affecting financial judgment

☐ Inability to meet basic personal needs despite adequate income

☐ Beneficiary's own statements regarding their capabilities

1.4 Key Distinction: Representative Payee vs. Power of Attorney

Feature	Representative Payee	Power of Attorney
Appointing authority	Social Security Administration	Individual (principal)
Governing law	Federal (42 U.S.C. §§ 405(j), 1383(a)(2))	State law
Scope	Social Security/SSI benefits only	As defined in POA document
SSA recognition	Yes	No - SSA does not honor POA
Accountability	Annual SSA accounting required	Varies by state law
Termination	By SSA determination	By principal or operation of law
Criminal liability	Federal criminal penalties for misuse	State law remedies

CRITICAL: A power of attorney, conservatorship, or guardianship does not authorize an agent to receive Social Security or SSI benefits. A separate representative payee appointment through SSA is required. See 20 CFR § 404.2001.

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PART 2: BENEFICIARY INFORMATION WORKSHEET

Complete this worksheet to organize beneficiary information before visiting the SSA field office.

2.1 Beneficiary Identifying Information

Field	Entry
Full legal name	[________________________________]
Also known as (AKA)	[________________________________]
Social Security Number	[________________________________]
Date of birth	[__/__/____]
Place of birth	[________________________________]
Citizenship status	[________________________________]

2.2 Beneficiary Contact Information

Field	Entry
Current street address	[________________________________]
City	[________________________________]
State	[____]
ZIP code	[________________________________]
Mailing address (if different)	[________________________________]
Primary phone	[________________________________]
Secondary phone	[________________________________]
Email address	[________________________________]

2.3 Type of Benefits Currently Received or Applied For

☐ Social Security Retirement Insurance Benefits (Title II - RIB)

☐ Social Security Disability Insurance Benefits (Title II - DIB/SSDI)

☐ Supplemental Security Income (Title XVI - SSI)

☐ Childhood Disability Benefits (Title II - CDB)

☐ Survivor's Benefits (Widow/Widower/Child)

☐ Special Veterans Benefits (Title VIII - SVB)

☐ Lump-sum death payment

☐ Other: [________________________________]

2.4 Monthly Benefit Amounts

Benefit Type	Monthly Amount
Primary benefit (Title II)	$ [________________________________]
SSI federal payment	$ [________________________________]
SSI state supplement	$ [________________________________]
Other benefit amounts	$ [________________________________]
Total monthly benefits	$ [________________________________]

2.5 Current Living Situation

☐ Lives alone independently

☐ Lives with proposed representative payee

☐ Lives with spouse (not proposed payee)

☐ Lives with family member(s): [________________________________]

☐ Lives in assisted living facility: [________________________________]

☐ Lives in skilled nursing facility: [________________________________]

☐ Lives in group home/residential care: [________________________________]

☐ Lives in psychiatric facility: [________________________________]

☐ Lives in correctional institution: [________________________________]

☐ Experiencing homelessness

☐ Other: [________________________________]

2.6 Reason Representative Payee Is Needed

☐ Minor child (under 18 years of age)

☐ Court adjudication of legal incompetence (provide court order)

☐ Cognitive impairment (dementia, Alzheimer's disease, traumatic brain injury)

☐ Intellectual or developmental disability

☐ Serious mental illness (schizophrenia, bipolar disorder, severe depression)

☐ Physical disability preventing management of finances

☐ Substance use disorder (drug addiction or alcoholism)

☐ History of financial exploitation or mismanagement

☐ Beneficiary's voluntary request for payee appointment

☐ DA&A contributing factor material to disability determination

☐ Other: [________________________________]

Narrative description of circumstances requiring a payee:

[________________________________]

[________________________________]

[________________________________]

2.7 Beneficiary's Current Representative (if any)

Field	Entry
Current representative payee (if any)	[________________________________]
Reason for change (if replacing current payee)	[________________________________]
Guardian/conservator name (if any)	[________________________________]
Court of appointment	[________________________________]
Case number	[________________________________]
Date of appointment	[__/__/____]

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PART 3: PROPOSED PAYEE INFORMATION WORKSHEET

3.1 Applicant Identifying Information

Field	Entry
Full legal name	[________________________________]
Social Security Number (or EIN for organizations)	[________________________________]
Date of birth	[__/__/____]
Citizenship status	[________________________________]
Government-issued ID type and number	[________________________________]

3.2 Applicant Contact Information

Field	Entry
Current street address	[________________________________]
City	[________________________________]
State	[____]
ZIP code	[________________________________]
Primary phone	[________________________________]
Secondary phone	[________________________________]
Email address	[________________________________]
Employer name	[________________________________]
Employer address	[________________________________]

3.3 Relationship to Beneficiary

☐ Spouse

☐ Natural or adoptive parent (custodial)

☐ Natural or adoptive parent (non-custodial)

☐ Stepparent

☐ Adult child of beneficiary

☐ Grandparent

☐ Sibling

☐ Other relative (specify): [________________________________]

☐ Legal guardian or conservator (provide court order)

☐ Friend or neighbor

☐ State or local government agency

☐ Community-based nonprofit organization (501(c))

☐ Other qualified organization

☐ Other: [________________________________]

3.4 Living Arrangement and Contact with Beneficiary

Do you currently live with the beneficiary?

☐ Yes, same household

☐ No, separate households

If no, frequency of contact with beneficiary:

☐ Daily (in-person or by phone)

☐ Several times per week

☐ Weekly

☐ Biweekly

☐ Monthly

☐ Less than monthly

Distance from beneficiary's residence: [________________________________]

3.5 Qualifications and Suitability

☐ I have known the beneficiary for [____] years

☐ I am currently involved in the beneficiary's day-to-day care

☐ I have experience managing finances for others

☐ I have served as representative payee before

☐ I understand the legal duties and responsibilities of a representative payee

☐ I have no conflicts of interest regarding the beneficiary's benefits

☐ I am not a creditor of the beneficiary

☐ I have not been convicted of a disqualifying felony (see Part 6)

☐ I have not previously misused another person's Social Security benefits

☐ I consent to a background check by SSA

Prior representative payee experience:

Beneficiary (initials)	Relationship	Dates of Service	SSA Office Location
[________________________________]	[________________________________]	[________________________________]	[________________________________]
[________________________________]	[________________________________]	[________________________________]	[________________________________]

3.6 How Benefits Will Be Used

Describe your plan for managing the beneficiary's benefits, including housing, food, medical care, and savings:

[________________________________]

[________________________________]

[________________________________]

3.7 Bank Account for Benefit Deposits

Field	Entry
Financial institution name	[________________________________]
Account type	☐ Checking ☐ Savings
Routing number	[________________________________]
Account number	[________________________________]
Account title (must reflect payee relationship)	[________________________________]

Proper account titling examples:

• "[Beneficiary Name] by [Payee Name], Representative Payee"
• "[Payee Name], Representative Payee for [Beneficiary Name]"

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PART 4: SSA FORM SSA-11-BK PREPARATION GUIDE

4.1 About Form SSA-11-BK

The SSA-11-BK (Request to be Selected as Payee) is the official SSA form required for all representative payee applications. It is administered under OMB Control Number 0960-0014. The form may be completed:

☐ On paper (Form SSA-11-BK) during an in-person interview at a Social Security field office

☐ Electronically through the Electronic Representative Payee System (eRPS), with data entered by SSA field office personnel during the interview (SG-SSA-11)

NOTE: The SSA-11-BK generally requires a face-to-face interview at a Social Security field office. It is not available for self-service completion online by the applicant.

4.2 Information Sections on Form SSA-11-BK

The form collects information in the following categories. Use Parts 2 and 3 of this guide to prepare your responses in advance.

Section A -- Applicant Payee Information:

☐ Full legal name, SSN, date of birth

☐ Current address and telephone number

☐ Relationship to beneficiary

☐ Whether applicant lives with beneficiary

☐ Employment information

Section B -- Beneficiary Information:

☐ Beneficiary's full legal name, SSN, date of birth

☐ Beneficiary's current address

☐ Beneficiary's living arrangement and custody status

☐ Names and addresses of others who provide care

Section C -- Custodial and Care Information:

☐ Who has physical custody of beneficiary

☐ Where beneficiary resides

☐ Who provides daily care and supervision

☐ Any pending custody or guardianship proceedings

Section D -- Financial Information:

☐ How benefits will be used for beneficiary's needs

☐ Where benefits will be deposited (bank account information)

☐ Applicant's access to beneficiary's other income and assets

☐ Whether applicant is a creditor of beneficiary

Section E -- Suitability and Background:

☐ Whether applicant has been convicted of a felony

☐ Whether applicant has previously served as a representative payee

☐ Whether applicant has ever misused benefits

☐ Whether applicant has any conflicts of interest

☐ Consent to background investigation by SSA

Section F -- Certification and Signature:

☐ Certification under penalty of perjury that all information is true and correct

☐ Acknowledgment of representative payee responsibilities

☐ Applicant's signature and date

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PART 5: PAYEE SELECTION CRITERIA AND PREFERENCE ORDER

5.1 SSA Order of Preference for Adult Beneficiaries (18+)

SSA follows a regulatory order of preference when selecting a representative payee, though this order is flexible and subject to the best-interest determination. See 20 CFR § 404.2021(a); 20 CFR § 416.621(a).

Priority	Category
1	Advance designee selected by beneficiary (see Part 7)
2	Spouse (or other relative) who has custody or demonstrates strong concern for the beneficiary's well-being
3	Friend who has custody or demonstrates strong concern
4	Public or nonprofit agency or institution qualified under 42 U.S.C. § 405(j)(4)
5	Private for-profit institution licensed under state law with a bonded officer
6	Other persons qualified and willing to serve
7	State or local government agency performing income maintenance, social service, or health care functions

5.2 SSA Order of Preference for Minor Beneficiaries (Under 18)

Priority	Category
1	Advance designee selected by beneficiary's parent/guardian
2	Natural or adoptive parent with custody
3	Natural or adoptive parent without custody but demonstrating strong concern
4	Court-appointed legal guardian
5	Relative or stepparent with custody
6	Relative with strong concern but without custody
7	Qualified organization or agency
8	Other persons qualified and willing to serve

5.3 Factors SSA Weighs in Selection

SSA considers the totality of circumstances, including (20 CFR § 404.2020):

☐ Relationship to beneficiary and demonstrated concern for well-being

☐ Whether applicant lives with or near the beneficiary

☐ Knowledge of the beneficiary's needs and circumstances

☐ Ability to meet the responsibilities of payeeship

☐ Legal authority over the beneficiary (guardianship, conservatorship)

☐ Whether the beneficiary designated the applicant in advance

☐ Criminal history and background check results

☐ Prior representative payee service record

☐ Whether the applicant is a creditor of the beneficiary

☐ Any potential conflicts of interest

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PART 6: DISQUALIFICATION GROUNDS

6.1 Persons Who May Not Serve as Representative Payee

Under 20 CFR § 404.2022 and 42 U.S.C. § 405(j)(2)(B), the following persons are generally prohibited from serving as a representative payee:

Disqualifying Factor	Regulatory Basis	Exceptions
Conviction for human trafficking	20 CFR § 404.2022(a)	Custodial parent, custodial spouse, custodial grandparent, custodial court-appointed guardian; presidential/gubernatorial pardon
Conviction for false imprisonment or kidnapping	20 CFR § 404.2022(a)	Same as above
Conviction for rape or sexual assault	20 CFR § 404.2022(a)	Same as above
Conviction for first-degree homicide	20 CFR § 404.2022(a)	Same as above
Conviction for robbery	20 CFR § 404.2022(a)	Same as above
Conviction for fraud to obtain government assistance	20 CFR § 404.2022(a)	Same as above
Conviction for fraud by scheme	20 CFR § 404.2022(a)	Same as above
Conviction for theft of government funds/property	20 CFR § 404.2022(a)	Same as above
Conviction for abuse or neglect	20 CFR § 404.2022(a)	Same as above
Conviction for forgery	20 CFR § 404.2022(a)	Same as above
Conviction for identity theft or fraud	20 CFR § 404.2022(a)	Same as above
Attempt or conspiracy to commit any of the above	20 CFR § 404.2022(a)	Same as above
Prior misuse of SSA benefits	20 CFR § 404.2022(d)	Limited exceptions
Convicted felon under 42 U.S.C. § 408	42 U.S.C. § 405(j)(2)(B)(iii)	Custodial family member exceptions
Refusal to submit to background check	42 U.S.C. § 405(j)(2)(B)(ii)	None

6.2 Additional Restrictions

☐ An individual serving as a representative payee for 15 or more beneficiaries is generally considered an organizational payee and must meet organizational payee requirements

☐ SSA employees generally may not serve as representative payees except in limited circumstances

☐ Most creditors of the beneficiary may not serve (20 CFR § 404.2022(e))

☐ Health care facility administrators providing residential care may not serve unless no suitable alternative exists

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PART 7: ADVANCE DESIGNATION OF REPRESENTATIVE PAYEES

7.1 Overview

Effective March 17, 2020, the SSA implemented advance designation of representative payees under 20 CFR § 404.2018, pursuant to the Strengthening Protections for Social Security Beneficiaries Act of 2018 (Pub. L. 115-165, § 103). This allows a beneficiary to designate in advance up to three individuals to serve as their representative payee if one becomes necessary.

7.2 Eligibility to Make an Advance Designation

☐ Individual must be age 18 or older, or an emancipated minor

☐ Individual must be mentally capable at the time of designation

☐ SSA must not have information that the individual is legally incompetent

☐ Individual must not already have a representative payee

7.3 How to Make an Advance Designation

☐ During initial application for benefits (online, by phone, or in person)

☐ At any time by contacting SSA (in person, by phone, or through my Social Security account)

☐ Provide designee's name, telephone number, address, and relationship

☐ Specify order of priority if designating multiple individuals

7.4 Advance Designation Information

Priority	Designee Name	Relationship	Phone Number	Address
First	[________________________________]	[________________________________]	[________________________________]	[________________________________]
Second	[________________________________]	[________________________________]	[________________________________]	[________________________________]
Third	[________________________________]	[________________________________]	[________________________________]	[________________________________]

7.5 Modification or Withdrawal

☐ Advance designations may be changed at any time by contacting SSA

☐ Changes must include updated designee information and priority order

☐ The beneficiary may withdraw all advance designations at any time

☐ An advance designation does not guarantee appointment; SSA retains discretion to select the most suitable payee under 20 CFR § 404.2021

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PART 8: APPLICATION PROCESS AND INTERVIEW

8.1 Step-by-Step Application Process

STEP 1: Preparation (Before Visiting SSA)

☐ Complete the Beneficiary Information Worksheet (Part 2 of this guide)

☐ Complete the Proposed Payee Information Worksheet (Part 3 of this guide)

☐ Gather all required documentation (see Part 9)

☐ Open a dedicated bank account titled in a representative payee capacity (if not yet established)

☐ Review representative payee duties and responsibilities (Part 10)

☐ Identify your local SSA field office at https://www.ssa.gov/locator

STEP 2: Schedule an Appointment

☐ Call SSA at 1-800-772-1213 (TTY: 1-800-325-0778)

☐ Hours: Monday through Friday, 8:00 a.m. to 7:00 p.m. local time

☐ Request an appointment to apply as representative payee

☐ Ask what specific documents to bring for your situation

☐ Record appointment details below:

Field	Entry
Appointment date	[__/__/____]
Appointment time	[________________________________]
SSA field office address	[________________________________]
Confirmation number (if provided)	[________________________________]

STEP 3: Attend In-Person Interview

☐ Arrive at the SSA field office with all required documents

☐ Complete Form SSA-11-BK (administered by SSA technician)

☐ Provide government-issued photo identification

☐ Provide your Social Security number

☐ Answer all questions truthfully and completely

☐ Consent to background check

☐ Ask questions about payee duties if uncertain

STEP 4: SSA Review and Background Check

☐ SSA verifies applicant information and suitability

☐ SSA conducts criminal background check (required since January 1, 2019)

☐ SSA evaluates applicant against preference order (Part 5)

☐ SSA contacts beneficiary regarding proposed payee (if capable)

☐ SSA may interview the beneficiary separately

☐ Processing time: typically 2 to 6 weeks

STEP 5: Notification of Decision

☐ SSA issues written notice to applicant of approval or denial

☐ SSA issues written notice to beneficiary of payee appointment

☐ Both parties receive information about appeal rights

☐ If approved, SSA provides payee orientation materials

STEP 6: Commencement of Payee Duties

☐ Receive first benefit payment

☐ Confirm direct deposit or Direct Express card enrollment

☐ Begin maintaining records of all benefit receipts and expenditures

☐ Familiarize yourself with annual reporting requirements (Part 12)

☐ Retain copies of all SSA correspondence

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PART 9: REQUIRED DOCUMENTATION CHECKLIST

9.1 Documents the Applicant Must Bring

Identification (at least one required):

☐ Valid driver's license

☐ State-issued identification card

☐ U.S. passport or passport card

☐ Military identification

☐ Other government-issued photo ID: [________________________________]

Social Security Information:

☐ Applicant's Social Security card (or number)

☐ Beneficiary's Social Security number

☐ Beneficiary's date of birth

Legal Authority Documents (if applicable):

☐ Court order of guardianship or conservatorship (certified copy)

☐ Letters of guardianship or conservatorship (current/certified)

☐ Court order appointing custodian

☐ Adoption decree or order

☐ Custody order or parenting plan

Medical Documentation (if applicable):

☐ Letter from beneficiary's treating physician documenting incapacity to manage finances

☐ Psychiatric evaluation or psychological assessment

☐ Hospital discharge summary with functional assessment

☐ Medical records supporting the need for a representative payee

☐ Statement from social worker or care coordinator

For Minor Child Beneficiaries:

☐ Child's birth certificate (certified copy)

☐ Custody order or decree (if applicable)

☐ School enrollment records

☐ Evidence of child's living arrangements

Financial Information:

☐ Bank account information for benefit deposits (routing and account numbers)

☐ Evidence of beneficiary's other income (if known)

☐ Information about beneficiary's financial resources

For Organizational Payee Applicants:

☐ Articles of incorporation or organization

☐ IRS determination letter (501(c) status)

☐ Proof of bonding or insurance

☐ State license (if required)

☐ Employer Identification Number (EIN)

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PART 10: REPRESENTATIVE PAYEE DUTIES AND RESPONSIBILITIES

10.1 Fiduciary Standard

A representative payee serves in a fiduciary capacity and must act solely in the best interest of the beneficiary. The payee's primary duty is to use benefit payments for the beneficiary's current maintenance, including food, shelter, clothing, medical care, and personal needs. See 20 CFR § 404.2035; 20 CFR § 416.635.

10.2 Core Duties

A. Use Benefits for Current Maintenance Needs (20 CFR § 404.2040)

The representative payee must use benefits to meet the beneficiary's current needs in the following priority:

Priority	Category	Examples
1	Food and nutrition	Groceries, meals, nutritional supplements
2	Housing	Rent, mortgage, property taxes, homeowner's insurance
3	Utilities	Electric, gas, water, sewer, telephone, heating fuel
4	Clothing	Seasonal clothing, shoes, outerwear
5	Medical and dental care	Co-pays, prescriptions, dental, vision, medical devices, therapies not covered by insurance
6	Personal care	Hygiene products, toiletries, haircuts
7	Rehabilitation	Physical therapy, occupational therapy, vocational rehabilitation
8	Customary personal needs	Recreation, entertainment, small personal purchases

B. Save Excess Benefits (20 CFR § 404.2045)

☐ Any benefits not needed for current maintenance must be saved for the beneficiary

☐ Savings must be held in the beneficiary's interest (preferably in a federally insured account)

☐ Preferred savings vehicles: savings accounts, certificates of deposit, U.S. savings bonds

☐ Savings may be used for foreseeable future needs (e.g., anticipated medical expenses, housing deposits)

☐ For SSI recipients: savings must be monitored to avoid exceeding the resource limit ($2,000 for individuals, $3,000 for couples)

C. Maintain Records (20 CFR § 404.2065)

☐ Keep receipts for all expenditures on behalf of the beneficiary

☐ Maintain bank statements for all payee accounts

☐ Document how each month's benefits are spent

☐ Retain records for a minimum of two (2) years after filing each annual accounting report

☐ Make records available to SSA upon request

D. Report Changes to SSA

☐ Report all changes in the beneficiary's circumstances that may affect eligibility or benefit amount (see Part 16)

☐ Report changes in the payee's own circumstances

☐ Complete annual accounting reports (see Part 12)

10.3 Prohibited Conduct

The representative payee must NOT:

☐ Commingle the beneficiary's funds with the payee's own money or any other person's funds

☐ Use any portion of the beneficiary's benefits for the payee's own needs or expenses

☐ Use benefits for anyone other than the beneficiary

☐ Charge the beneficiary a fee for payee services (unless an authorized organizational payee under 20 CFR § 404.2040a)

☐ Retain benefit payments after the beneficiary's death (must return to SSA)

☐ Deposit benefits in an account titled only in the payee's name

☐ Invest beneficiary funds in speculative investments (stocks, bonds, mutual funds) without SSA approval

☐ Withhold benefits as punishment or behavioral control

☐ Make loans from the beneficiary's funds to the payee or any third party

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PART 11: FINANCIAL MANAGEMENT REQUIREMENTS

11.1 Bank Account Requirements

Account Titling (20 CFR § 404.2035):

Benefits must be maintained in a separate, dedicated account properly titled to reflect the representative payee relationship. Acceptable titling formats:

Format	Example
"[Beneficiary] by [Payee], Representative Payee"	"John A. Smith by Mary B. Smith, Representative Payee"
"[Payee], Representative Payee for [Beneficiary]"	"Mary B. Smith, Representative Payee for John A. Smith"

Account Requirements:

☐ Account must be separate from payee's personal accounts

☐ Account must be at a federally insured financial institution (FDIC or NCUA)

☐ Payee must be an authorized signer on the account

☐ Beneficiary's funds must not be commingled with any other person's funds

☐ Joint accounts with the payee are not appropriate (unless the payee is also the spouse and the account holds only the beneficiary's Social Security benefits)

11.2 Electronic Payment Requirements

SSA requires all benefit payments to be received electronically. Representative payees must select one of the following:

Option A: Direct Deposit

☐ Benefits deposited directly into a bank account

☐ Requires bank routing number and account number

☐ Enrolled through SSA during application or by calling 1-800-772-1213

Option B: Direct Express Debit MasterCard

☐ Prepaid debit card issued by Comerica Bank

☐ No bank account required

☐ Free cash withdrawals at participating ATMs

☐ Online account management at https://www.USDirectExpress.com

☐ Enrollment phone: 1-800-333-1795

Direct Express Feature	Details
Monthly fee	$0
Cash withdrawal (in-network ATM)	Free (one per month)
Cash withdrawal (out-of-network ATM)	$0.85 per transaction
Online balance inquiry	Free
Customer service	1-800-333-1795

11.3 Spending Priority Guidelines

When the beneficiary's monthly benefit is insufficient to cover all expenses, the payee should prioritize spending in the following order:

Priority	Expense Category	Monthly Allocation
1	Housing (rent/mortgage, property tax, insurance)	$ [________________________________]
2	Utilities (electric, gas, water, phone)	$ [________________________________]
3	Food and nutrition	$ [________________________________]
4	Medical care (co-pays, prescriptions, supplies)	$ [________________________________]
5	Clothing	$ [________________________________]
6	Personal needs and hygiene	$ [________________________________]
7	Transportation	$ [________________________________]
8	Recreation and personal allowance	$ [________________________________]
9	Savings for future needs	$ [________________________________]
	Total	$ [________________________________]

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PART 12: ANNUAL ACCOUNTING AND REPORTING

12.1 Annual Representative Payee Report

Most representative payees must complete an annual accounting report to SSA documenting how benefits were used during the reporting period. SSA uses the following forms:

Form	Description	Who Files
SSA-6230 (Representative Payee Report)	Standard payee accounting for Title II adult beneficiaries	Individual payees for adult beneficiaries
SSA-6233 (Representative Payee Report of Benefits and Dedicated Account)	Accounting for SSI child beneficiaries with dedicated accounts	Payees for SSI children under 18
SSA-623 (Representative Payee Report)	Organizational payee accounting	Organizational payees
SSA-6234 (Representative Payee Report)	Payee accounting for Title XVI (SSI) adult beneficiaries	Individual payees for SSI adults

12.2 Online Filing

Representative payees may file the annual accounting report online at:

https://www.ssa.gov/payee/form/index.htm

☐ Access information is provided on the paper form mailed by SSA

☐ Online filing is available 24 hours a day, 7 days a week

☐ Electronic filing provides immediate confirmation

12.3 Exemptions from Annual Reporting

Under the Strengthening Protections for Social Security Beneficiaries Act of 2018 (Pub. L. 115-165, § 102) and implementing regulations, the following payees are exempt from annual accounting:

☐ Natural or adoptive parent of a minor child beneficiary who lives in the same household

☐ Legal guardian of a minor child beneficiary who lives in the same household

☐ Natural or adoptive parent of a disabled adult beneficiary (whose disability began before age 22) who lives in the same household

☐ Spouse of the beneficiary

IMPORTANT: Even exempt payees must maintain records and make them available to SSA upon request. Exemption from annual reporting does not exempt the payee from any other duty or responsibility.

12.4 What the Annual Report Covers

The annual accounting report requires the payee to disclose the following information for the reporting period:

Category	Information Required
Total benefits received	Amount of all SS/SSI payments received during the period
Food and shelter	Total spent on food, rent/mortgage, utilities
Clothing and personal needs	Total spent on clothing, hygiene, personal items
Medical and dental care	Total spent on health care, medications, therapies
Recreation and other	Total spent on entertainment, travel, other
Total savings	Amount saved on behalf of beneficiary at end of period
Account balance	Current balance in representative payee account(s)
Changes in living arrangement	Any changes in where or with whom beneficiary lives
Changes in beneficiary's condition	Any improvement or decline in beneficiary's capability

12.5 Failure to File Annual Report

☐ SSA will send a reminder notice if the report is not filed timely

☐ Continued failure to file may result in payee removal and selection of a new payee

☐ SSA may conduct an investigation into the payee's management of benefits

☐ Benefits may be suspended until a new payee is appointed or the report is filed

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PART 13: DEDICATED ACCOUNTS FOR SSI MINORS

13.1 When a Dedicated Account Is Required

Under 42 U.S.C. § 1383(a)(2)(F) and 20 CFR § 416.640, when SSA awards past-due SSI benefits to a minor child in an amount that exceeds six times the current monthly benefit (or involves a pattern of past-due payments), the representative payee must establish a dedicated account at a financial institution to receive the past-due benefits.

13.2 Dedicated Account Requirements

☐ Must be a checking, savings, or money market account at a federally insured financial institution

☐ Must be titled to reflect the representative payee relationship

☐ May not be in the form of certificates of deposit, mutual funds, stocks, bonds, or trusts

☐ Must be separate from any account holding regular monthly benefits

☐ Only past-due SSI benefits (and subsequent accruals) may be deposited

13.3 Permissible Uses of Dedicated Account Funds

Dedicated account funds may be used only for the following purposes (20 CFR § 416.640(e)):

☐ Medical treatment

☐ Education or job skills training

☐ Personal needs assistance (if related to the child's impairment)

☐ Special equipment (if related to the child's impairment)

☐ Housing modification (if related to the child's impairment)

☐ Therapy or rehabilitation (if related to the child's impairment)

☐ Other items and services related to the child's impairment as approved by SSA

13.4 Misapplication of Dedicated Account Funds

Under 20 CFR § 416.640(f), use of dedicated account funds for any unauthorized purpose constitutes misapplication of benefits. The payee will be liable to SSA for the full amount of misapplied funds and may be subject to removal and criminal prosecution.

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PART 14: MONTHLY BENEFIT TRACKING WORKSHEET

Complete this worksheet each month. Retain for a minimum of two years after filing each annual accounting report.

Reporting Period: Month of [________________________________] Year [____]

Beneficiary Name: [________________________________]

Payee Name: [________________________________]

14.1 Income

Source	Amount
Social Security / SSDI benefit received	$ [________________________________]
SSI federal payment received	$ [________________________________]
SSI state supplement received	$ [________________________________]
Other income received on behalf of beneficiary	$ [________________________________]
Carry-forward from prior month savings	$ [________________________________]
Total available	$ [________________________________]

14.2 Expenditures

Category	Amount	Receipt/Documentation
Housing (rent/mortgage)	$ [________________________________]	☐ Retained
Property tax / insurance	$ [________________________________]	☐ Retained
Utilities (electric, gas, water, phone)	$ [________________________________]	☐ Retained
Food and groceries	$ [________________________________]	☐ Retained
Clothing	$ [________________________________]	☐ Retained
Medical / dental (co-pays, prescriptions)	$ [________________________________]	☐ Retained
Personal care (hygiene, haircut)	$ [________________________________]	☐ Retained
Transportation	$ [________________________________]	☐ Retained
Recreation / entertainment	$ [________________________________]	☐ Retained
Other: [________________________________]	$ [________________________________]	☐ Retained
Other: [________________________________]	$ [________________________________]	☐ Retained
Total expenditures	$ [________________________________]

14.3 Savings

Description	Amount
Amount saved this month	$ [________________________________]
Cumulative savings balance	$ [________________________________]
Account number (last 4 digits)	[____]

14.4 Monthly Certification

I certify that the above accounting is true, accurate, and complete, and that all expenditures were made for the sole benefit of the beneficiary.

Payee signature: [________________________________]

Date: [__/__/____]

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PART 15: ANNUAL SUMMARY WORKSHEET

Calendar Year: [____]

Beneficiary Name: [________________________________]

Payee Name: [________________________________]

Month	Benefits Received	Total Spent	Amount Saved	Cumulative Savings
January	$ [________________________________]	$ [________________________________]	$ [________________________________]	$ [________________________________]
February	$ [________________________________]	$ [________________________________]	$ [________________________________]	$ [________________________________]
March	$ [________________________________]	$ [________________________________]	$ [________________________________]	$ [________________________________]
April	$ [________________________________]	$ [________________________________]	$ [________________________________]	$ [________________________________]
May	$ [________________________________]	$ [________________________________]	$ [________________________________]	$ [________________________________]
June	$ [________________________________]	$ [________________________________]	$ [________________________________]	$ [________________________________]
July	$ [________________________________]	$ [________________________________]	$ [________________________________]	$ [________________________________]
August	$ [________________________________]	$ [________________________________]	$ [________________________________]	$ [________________________________]
September	$ [________________________________]	$ [________________________________]	$ [________________________________]	$ [________________________________]
October	$ [________________________________]	$ [________________________________]	$ [________________________________]	$ [________________________________]
November	$ [________________________________]	$ [________________________________]	$ [________________________________]	$ [________________________________]
December	$ [________________________________]	$ [________________________________]	$ [________________________________]	$ [________________________________]
ANNUAL TOTAL	$ [________________________________]	$ [________________________________]	$ [________________________________]	$ [________________________________]

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PART 16: CHANGES IN CIRCUMSTANCES REPORTING

16.1 Events the Payee Must Report to SSA

The representative payee must promptly notify SSA of any of the following changes. Failure to report may result in overpayments, underpayments, or removal as payee.

Changes Affecting the Beneficiary:

☐ Death of the beneficiary

☐ Change in beneficiary's address or living arrangements

☐ Beneficiary enters or leaves an institution (nursing home, psychiatric facility, correctional institution)

☐ Improvement in beneficiary's mental or physical condition

☐ Beneficiary begins or stops working

☐ Change in beneficiary's marital status

☐ Beneficiary leaves the United States

☐ Change in beneficiary's other income or resources

☐ For SSI: change in beneficiary's resources approaching the $2,000/$3,000 limit

☐ For SSI: change in in-kind support and maintenance received by beneficiary

☐ Beneficiary is subject to an unsatisfied warrant for a felony

Changes Affecting the Payee:

☐ Payee's change of address

☐ Payee's change in relationship to beneficiary (e.g., divorce from beneficiary)

☐ Payee no longer wishes to serve or is unable to serve

☐ Payee is convicted of a felony

☐ Payee changes the bank account where benefits are deposited

☐ Payee has a change in financial circumstances affecting ability to serve

16.2 How to Report Changes

Method	Details
Telephone	1-800-772-1213 (TTY: 1-800-325-0778)
In person	Visit local SSA field office
Online	https://www.ssa.gov (limited reporting available)
Written correspondence	Send to local SSA field office by certified mail

16.3 Reporting Log

Date Reported	Event/Change	Method of Report	SSA Reference/Confirmation
[__/__/____]	[________________________________]	[________________________________]	[________________________________]
[__/__/____]	[________________________________]	[________________________________]	[________________________________]
[__/__/____]	[________________________________]	[________________________________]	[________________________________]
[__/__/____]	[________________________________]	[________________________________]	[________________________________]

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PART 17: MISUSE, PENALTIES, AND LIABILITY

17.1 Definition of Misuse

Under 20 CFR § 404.2041, misuse of benefits occurs when a representative payee receives payment for the use and benefit of a beneficiary and converts such payment, or any part thereof, to a use other than for the use and benefit of that beneficiary. This includes:

☐ Using benefits for the payee's own expenses

☐ Using benefits for the expenses of a person other than the beneficiary

☐ Failing to use benefits for the beneficiary's current maintenance needs

☐ Failing to save benefits not needed for current needs

☐ Using dedicated account funds for unauthorized purposes

17.2 Criminal Penalties

Misuse of Social Security or SSI benefits is a federal crime under 42 U.S.C. § 408 (Title II) and 42 U.S.C. § 1383a (Title XVI):

Offense	Penalty
First conviction of benefit misuse	Felony: fine under 18 U.S.C. and/or imprisonment up to 5 years
Second or subsequent conviction	Felony: fine under 18 U.S.C. and/or imprisonment up to 5 years
Fraud in obtaining payee status	Felony: fine and/or imprisonment up to 5 years
Conspiracy to misuse benefits	Subject to federal conspiracy penalties under 18 U.S.C. § 371

17.3 Administrative Consequences

☐ Immediate removal as representative payee

☐ Prohibition from serving as representative payee for any beneficiary in the future

☐ SSA will seek restitution of all misused funds

☐ If misused by an individual payee, SSA will repay the beneficiary from SSA funds and pursue recovery from the payee

☐ If misused by an organizational payee, SSA will repay the beneficiary and seek recovery from the organization

☐ Referral to the SSA Office of Inspector General for criminal investigation

☐ Referral to the U.S. Department of Justice for prosecution

17.4 SSA Oversight and Monitoring

SSA conducts the following oversight activities:

☐ Annual accounting review (Form SSA-6230 or equivalent)

☐ Periodic on-site reviews of payees (both individual and organizational)

☐ Investigation of complaints or allegations of misuse

☐ Review of payee suitability when risk indicators are present

☐ Coordination with Adult Protective Services and law enforcement agencies

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PART 18: CHALLENGING OR CHANGING A PAYEE

18.1 Beneficiary's Right to Appeal Payee Appointment

Under 42 U.S.C. § 405(j)(2)(E) and 20 CFR § 404.2030, a beneficiary who is dissatisfied with the appointment of a representative payee or the selection of a particular payee has the right to:

☐ Receive written notice of the initial determination to appoint a payee

☐ Request reconsideration within 60 days of receiving the notice

☐ Request a hearing before an Administrative Law Judge (ALJ) if reconsideration is unfavorable

☐ Request review by the Appeals Council if the ALJ decision is unfavorable

☐ Seek judicial review in federal district court if the Appeals Council decision is unfavorable

18.2 Requesting a New Representative Payee

A change of representative payee may be requested when:

☐ Current payee dies or becomes incapacitated

☐ Current payee no longer wishes to serve

☐ Current payee has misused benefits or is suspected of misuse

☐ Beneficiary requests a different payee

☐ A more suitable payee becomes available

☐ Payee's relationship to beneficiary changes (e.g., divorce)

☐ Payee moves away from beneficiary

☐ Payee is convicted of a disqualifying felony

To request a change:

☐ Contact local SSA field office by phone or in person

☐ Explain the reason for the requested change

☐ The proposed new payee must complete Form SSA-11-BK

☐ Provide documentation supporting the need for change

18.3 When the Beneficiary Regains Capability

A beneficiary may request to manage their own benefits if:

☐ Medical evidence demonstrates improvement in condition

☐ Beneficiary can show ability to manage finances independently

☐ Court restoration of legal capacity (if previously adjudicated incompetent)

☐ SSA determines the beneficiary no longer meets the criteria for representative payment

Process to terminate payeeship:

☐ Beneficiary contacts SSA and requests to receive benefits directly

☐ SSA may require medical evidence or conduct a capability assessment

☐ SSA issues a determination; both payee and beneficiary receive written notice

☐ Either party may appeal the determination through the standard appeals process

18.4 Appeal Tracking Log

Date	Action Taken	SSA Reference	Outcome/Status
[__/__/____]	[________________________________]	[________________________________]	[________________________________]
[__/__/____]	[________________________________]	[________________________________]	[________________________________]
[__/__/____]	[________________________________]	[________________________________]	[________________________________]

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PART 19: ORGANIZATIONAL REPRESENTATIVE PAYEES

19.1 Types of Organizational Payees

Type	Description	Regulatory Basis
State or local government agency	Agency with fiduciary responsibilities or providing income maintenance, social services, or health care	20 CFR § 404.2040a(b)(1)
Community-based nonprofit	Tax-exempt under IRC § 501(c), bonded/insured, and licensed as required by state law	20 CFR § 404.2040a(b)(2)
Fee-for-service organizational payee	Qualified organization authorized by SSA to collect fees	20 CFR § 404.2040a

19.2 Fee Authorization for Organizational Payees

Under 20 CFR § 404.2040a, a qualified organization may collect a monthly fee from the beneficiary's payments to cover the cost of providing payee services, subject to the following conditions:

☐ Organization must request and receive written authorization from SSA before collecting any fee

☐ Organization must serve at least five (5) beneficiaries concurrently

☐ Organization must be bonded or insured against loss or misuse

☐ Organization must not be a creditor of the beneficiary

☐ Fee amount is set by SSA and adjusted annually by the COLA percentage

☐ Organization must be tax-exempt under IRC § 501(c) (or a government agency)

☐ The fee may not exceed 10 percent of the monthly benefit or $47.00 (2025 amount, adjusted annually), whichever is less

19.3 Organizational Payee Oversight

☐ SSA conducts periodic on-site reviews of organizational payees

☐ Organizations must submit annual accounting for all beneficiaries served

☐ SSA reviews financial management, record-keeping, and service quality

☐ Organizations must maintain fiduciary insurance or bonding

☐ Organizations must comply with all applicable state licensing requirements

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PART 20: PAYEE RESPONSIBILITY ACKNOWLEDGMENT

20.1 Declaration of Understanding

By signing below, I acknowledge and agree to the following:

☐ I have read and understand the duties and responsibilities of a representative payee as described in this guide and as set forth in 20 CFR § 404.2035 (or 20 CFR § 416.635 for SSI)

☐ I will use the beneficiary's benefits solely for the beneficiary's current maintenance needs, including food, shelter, clothing, medical care, and personal needs

☐ I will save any benefits not needed for the beneficiary's current maintenance for the beneficiary's future needs

☐ I will not commingle the beneficiary's funds with my own or any other person's funds

☐ I will not use any portion of the beneficiary's benefits for my own needs or expenses

☐ I will not charge the beneficiary any fee for my services as payee (unless I am an authorized organizational payee)

☐ I will maintain a dedicated bank account properly titled to reflect the representative payee relationship

☐ I will keep accurate and complete records of all benefits received, expended, and saved on behalf of the beneficiary

☐ I will retain all receipts, bank statements, and documentation for a minimum of two (2) years after filing each annual accounting report

☐ I will complete and timely file the annual Representative Payee Report (Form SSA-6230 or applicable form), unless exempted under Pub. L. 115-165, § 102

☐ I will promptly notify SSA of any change in the beneficiary's circumstances that may affect benefit eligibility or amount, including but not limited to changes in address, living arrangement, income, resources, marital status, institutional status, employment, or medical condition

☐ I will promptly notify SSA of any change in my own circumstances that may affect my suitability as payee

☐ I will return any benefits received after the beneficiary's death to SSA

☐ I understand that misuse of the beneficiary's benefits is a federal crime punishable by fine and imprisonment under 42 U.S.C. § 408 and/or 42 U.S.C. § 1383a

☐ I understand that SSA may remove me as representative payee at any time if it determines that I am no longer suitable or that the beneficiary's interests are not being served

☐ I consent to a background check by the Social Security Administration

20.2 Signature Block

I certify under penalty of perjury that I have read, understand, and agree to all of the above responsibilities and obligations, and that I will faithfully discharge my duties as representative payee for the named beneficiary.

Proposed Representative Payee:

Signature: [________________________________]

Printed name: [________________________________]

Date: [__/__/____]

Social Security Number: [________________________________]

Witness (recommended but not required by SSA):

Signature: [________________________________]

Printed name: [________________________________]

Date: [__/__/____]

Relationship to payee or beneficiary: [________________________________]

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PART 21: IMPORTANT CONTACTS AND RESOURCES

21.1 Social Security Administration

Contact	Information
National toll-free number	1-800-772-1213
TTY/TDD	1-800-325-0778
Hours	Monday - Friday, 8:00 a.m. - 7:00 p.m. local time
Website	https://www.ssa.gov
Office locator	https://www.ssa.gov/locator
Representative Payee Program page	https://www.ssa.gov/payee/
Online payee accounting	https://www.ssa.gov/payee/form/index.htm
my Social Security account	https://www.ssa.gov/myaccount
Local SSA field office	[________________________________]
Local office address	[________________________________]
Local office phone	[________________________________]

21.2 Direct Express Card

Contact	Information
Customer service	1-800-333-1795
Website	https://www.USDirectExpress.com
Hearing impaired	1-866-569-0447

21.3 SSA Office of Inspector General

Contact	Information
Fraud hotline	1-800-269-0271
Online fraud reporting	https://oig.ssa.gov/report
TTY	1-866-501-2101

21.4 Additional Resources

Resource	Contact Information
Area Agency on Aging	[________________________________]
Adult Protective Services	[________________________________]
Eldercare Locator	1-800-677-1116 / https://eldercare.acl.gov
Legal Aid/Legal Services	[________________________________]
Social worker/case manager	[________________________________]
Beneficiary's treating physician	[________________________________]
Elder law attorney	[________________________________]
State ombudsman	[________________________________]
National Alliance on Mental Illness (NAMI)	1-800-950-6264 / https://www.nami.org

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SOURCES AND REFERENCES

Federal Statutes

• 42 U.S.C. § 405(j) -- Representative Payee for Title II Benefits
• 42 U.S.C. § 1383(a)(2) -- Representative Payee for SSI Benefits
• 42 U.S.C. § 408 -- Criminal Penalties for Social Security Fraud
• 42 U.S.C. § 1383a -- Criminal Penalties for SSI Fraud
• 42 U.S.C. § 1007 -- Representative Payees for Special Veterans Benefits
• Pub. L. 115-165 -- Strengthening Protections for Social Security Beneficiaries Act of 2018

Federal Regulations

• 20 CFR Part 404, Subpart U (§§ 404.2001-404.2065) -- Title II Representative Payment
• 20 CFR Part 416, Subpart F (§§ 416.601-416.665) -- SSI Representative Payment
• 20 CFR § 404.2018 -- Advance Designation of Representative Payees
• 20 CFR § 404.2021 -- Order of Preference in Selecting a Representative Payee
• 20 CFR § 404.2022 -- Who May Not Serve as a Representative Payee
• 20 CFR § 404.2040 -- Use of Benefit Payments
• 20 CFR § 404.2040a -- Compensation for Qualified Organizations
• 20 CFR § 416.640 -- Dedicated Accounts for SSI Past-Due Benefits

SSA Program Operations Manual System (POMS)

• GN 00502.107 -- The Representative Payee Application
• GN 00502.115 -- The SSA-11-BK, Request to be Selected as Payee
• GN 00502.085 -- Advance Designation of Representative Payee
• GN 00605.010 -- The Representative Payee Accounting Report Forms

SSA Resources

• SSA Representative Payee Program
• Representative Payee FAQ
• Representative Payee Accounting FAQ
• Internet Representative Payee Accounting Report
• Guide for Organizational Representative Payees

Federal Register Notices

• Advance Designation of Representative Payees (85 FR 7828, Feb. 11, 2020)
• Prohibiting Persons With Certain Criminal Convictions From Serving as Representative Payees (83 FR 51492, Oct. 11, 2018)
• Reducing Burden on Families Acting as Representative Payees (87 FR 35784, June 13, 2022)

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This template is provided for informational and preparatory purposes only and does not constitute legal advice. It is not a substitute for Form SSA-11-BK or any other official SSA form. The Social Security Administration is the sole authority for representative payee appointments. Contact SSA at 1-800-772-1213 or visit https://www.ssa.gov/payee/ for official guidance. Consult a qualified elder law attorney for advice specific to your circumstances.