Representative Payee Application Worksheet

(Preparation Guide for SSA Form SSA-11)

PURPOSE

This worksheet helps you prepare to apply to become a Representative Payee for someone who receives Social Security or Supplemental Security Income (SSI) benefits. The actual application is made through the Social Security Administration (SSA) using Form SSA-11 (Request to be Selected as Payee).

WHAT IS A REPRESENTATIVE PAYEE?

A Representative Payee is a person or organization appointed by the Social Security Administration to receive Social Security or SSI benefits on behalf of a beneficiary who is unable to manage their own finances. The payee is responsible for:

• Receiving the beneficiary's monthly benefits
• Using the funds to pay for the beneficiary's current needs (food, shelter, clothing, medical care)
• Saving any remaining funds for the beneficiary's future needs
• Keeping records of how the money is spent
• Reporting to SSA about how the benefits were used
• Reporting changes in the beneficiary's circumstances

SECTION 1: BENEFICIARY INFORMATION

Person Who Needs a Representative Payee

Full Legal Name: _______________________________________________

Social Security Number: _______________________________________________

Date of Birth: _______________________________________________

Current Address:
_______________________________________________
_______________________________________________

Phone: _______________________________________________

Type of Benefits Received:
☐ Social Security (retirement, survivors, disability - RSDI)
☐ Supplemental Security Income (SSI)
☐ Both

Approximate Monthly Benefit Amount: $_______________________________________________

Current Payee (if any): _______________________________________________

Reason Representative Payee is Needed

Why does this person need a representative payee?

☐ Minor child (under 18)
☐ Legal incompetence (court-declared)
☐ Medical condition affecting ability to manage finances
☐ Mental impairment
☐ Drug or alcohol addiction
☐ Other incapacity: _______________________________________________

Describe the beneficiary's limitations:
_______________________________________________
_______________________________________________
_______________________________________________

Is there a physician's statement available?
☐ Yes (physician: _______________________________________________)
☐ No

Is there a court-appointed guardian or conservator?
☐ No
☐ Yes - Name: _______________________________________________
Relationship: _______________________________________________
Date of Appointment: _______________________________________________

SECTION 2: PROPOSED REPRESENTATIVE PAYEE INFORMATION

Your Information (Proposed Payee)

Full Legal Name: _______________________________________________

Social Security Number: _______________________________________________

Date of Birth: _______________________________________________

Current Address:
_______________________________________________
_______________________________________________

Phone: _______________________________________________

Email: _______________________________________________

Relationship to Beneficiary:
☐ Spouse
☐ Parent
☐ Child
☐ Other relative: _______________________________________________
☐ Friend
☐ Legal guardian/conservator
☐ Social service agency
☐ Nursing facility
☐ Other organization: _______________________________________________

Your Background

Are you a U.S. citizen?
☐ Yes
☐ No - Immigration status: _______________________________________________

Do you receive Social Security or SSI benefits?
☐ Yes - Type: _______________________________________________
☐ No

Do you have a representative payee for your own benefits?
☐ Yes ☐ No ☐ N/A

Criminal History Questions

Have you ever been convicted of a felony?
☐ No
☐ Yes - Describe: _______________________________________________

Have you ever been convicted of a crime involving fraud, theft, or misuse of funds?
☐ No
☐ Yes - Describe: _______________________________________________

Have you ever had a finding of misuse of benefits as a representative payee?
☐ No
☐ Yes - Describe: _______________________________________________

Have you ever been removed as a representative payee?
☐ No
☐ Yes - Explain: _______________________________________________

SECTION 3: LIVING SITUATION

Beneficiary's Living Arrangements

Where does the beneficiary currently live?
☐ With you (the proposed payee)
☐ In their own home
☐ With other family members: _______________________________________________
☐ Nursing home: _______________________________________________
☐ Assisted living: _______________________________________________
☐ Group home: _______________________________________________
☐ Other: _______________________________________________

If not living with you, how often do you see the beneficiary?
☐ Daily
☐ Several times per week
☐ Weekly
☐ Monthly
☐ Less often: _______________________________________________

Custody and Responsibility

Do you have legal custody of the beneficiary?
☐ Yes ☐ No ☐ N/A (beneficiary is an adult)

Do you have primary responsibility for the beneficiary's care?
☐ Yes ☐ No

If no, who has primary care responsibility?
_______________________________________________

SECTION 4: FINANCIAL INFORMATION

Your Financial Responsibility

Do you receive any payment for caring for the beneficiary?
☐ No
☐ Yes - Amount: $_______________ per _______________
Source: _______________________________________________

Will you charge a fee for serving as representative payee?
☐ No
☐ Yes (Note: Individual payees generally cannot charge fees; organizational payees may collect up to $49/month for RSDI, $39/month for SSI, with authorized fee-for-service status)

Beneficiary's Financial Needs

What are the beneficiary's current monthly expenses?

Does the beneficiary have any savings?
☐ No
☐ Yes - Approximate amount: $_______________________________________________

Does the beneficiary have any debts?
☐ No
☐ Yes - Approximate amount: $_______________________________________________
For: _______________________________________________

SECTION 5: ORGANIZATIONAL PAYEE (If Applicable)

If the Proposed Payee is an Organization

Organization Name: _______________________________________________

Type of Organization:
☐ Social service agency
☐ Nursing facility
☐ State/local government agency
☐ Financial institution
☐ Other: _______________________________________________

Organization Address:
_______________________________________________
_______________________________________________

Contact Person: _______________________________________________

Phone: _______________________________________________

Does the organization have SSA authorization to serve as a fee-for-service payee?
☐ Yes ☐ No ☐ Application pending

Is the organization bonded?
☐ Yes - Amount: $_______________________________________________
☐ No

SECTION 6: HOW BENEFITS WILL BE MANAGED

Benefit Management Plan

How will you receive the benefits?
☐ Direct deposit to a dedicated payee account
☐ Direct deposit to shared account
☐ Paper check

What financial institution will you use?

Bank/Credit Union: _______________________________________________

Address: _______________________________________________

Account Type: ☐ Checking ☐ Savings

Will the account be in the beneficiary's name?
☐ Yes - Account will be titled "[Beneficiary Name] by [Payee Name], Representative Payee"
☐ No - Explain: _______________________________________________

Record Keeping

How will you track spending?
☐ Dedicated checking/savings account
☐ Spreadsheet or written log
☐ Receipts kept in organized file
☐ Other: _______________________________________________

Are you aware of the requirement to keep records and file annual accountings with SSA?
☐ Yes
☐ No (Note: You will be required to file a Representative Payee Report annually)

SECTION 7: APPLICATION PROCESS CHECKLIST

Documents to Bring to SSA Appointment

☐ Your photo ID (driver's license, passport)
☐ Your Social Security card or number
☐ Beneficiary's Social Security number
☐ Proof of relationship (if applicable)
☐ Guardianship/conservatorship order (if applicable)
☐ Medical evidence of beneficiary's incapacity (if available)
☐ Proof of your address
☐ Information about beneficiary's living situation and expenses

Application Steps

☐ Step 1: Call SSA at 1-800-772-1213 to schedule an appointment or visit local office

☐ Step 2: Complete Form SSA-11 (Request to be Selected as Payee) at the SSA office

☐ Step 3: SSA will conduct a background check and may interview the beneficiary

☐ Step 4: SSA will make a determination and notify you

☐ Step 5: If approved, begin receiving benefits and managing them for the beneficiary

☐ Step 6: File annual Representative Payee Report (Form SSA-6230 or SSA-6233)

SECTION 8: REPRESENTATIVE PAYEE RESPONSIBILITIES

Understanding Your Duties

As a Representative Payee, you must:

☐ Use benefits for current needs first: Food, shelter, clothing, medical care, personal comfort items

☐ Save remaining funds: Keep excess funds in an interest-bearing account for the beneficiary's future needs

☐ Maintain records: Keep receipts and records of all expenditures

☐ Report to SSA: File the annual Representative Payee Report

☐ Report changes: Notify SSA of any changes affecting benefits, including:
- Change of address
- Changes in living situation
- Income changes
- Death of beneficiary
- Improvement in beneficiary's condition
- Changes affecting SSI eligibility

☐ Return conserved funds: If you stop being payee, return any saved funds to SSA or the new payee

☐ Do not commingle funds: Keep the beneficiary's funds separate from your own

What You Cannot Do

☐ Use the beneficiary's funds for your own benefit
☐ Charge a fee (unless you are an authorized fee-for-service organizational payee)
☐ Put funds in your personal account
☐ Invest funds in risky investments
☐ Make loans from the beneficiary's funds

SECTION 9: IMPORTANT CONTACTS

Social Security Administration:
- National Number: 1-800-772-1213
- TTY: 1-800-325-0778
- Website: www.ssa.gov

Local SSA Office:
Name: _______________________________________________
Address: _______________________________________________
Phone: _______________________________________________

SSA Representative Payee Program:
Website: www.ssa.gov/payee

SECTION 10: ANNUAL REPORTING REQUIREMENT

Representative Payee Report

You must complete and return the annual Representative Payee Report (Form SSA-6230 for most beneficiaries, Form SSA-6233 for beneficiaries in institutions).

The report asks about:
- Where the beneficiary lived during the year
- How much was spent on food and housing
- How much was spent on other items
- How much money was saved for the beneficiary
- Any changes in the beneficiary's situation

Failure to file the annual report can result in:
- Suspension of benefits
- Removal as representative payee
- Requirement to repay benefits

SECTION 11: SIGNATURE AND ACKNOWLEDGMENT

I understand that:

1. This worksheet is for preparation purposes only and the actual application must be made to SSA.

2. As a representative payee, I have a fiduciary duty to manage benefits solely for the benefit of the beneficiary.

3. Misuse of benefits is a federal crime punishable by fines and imprisonment.

4. I must keep accurate records and file annual reports with SSA.

5. SSA may conduct reviews and request additional information at any time.

Proposed Payee Signature: _________________________________

Printed Name: _________________________________

Date: _________________________________

NOTES AND ADDITIONAL INFORMATION

_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

This worksheet is provided for informational and preparation purposes only. It is not the official SSA application form. You must apply directly with the Social Security Administration using Form SSA-11. For questions about representative payee responsibilities, contact SSA at 1-800-772-1213 or visit www.ssa.gov/payee.