Ssa 11 PDF Template

Ssa 11 PDF Template

The SSA-11 form, also known as the Request to be Selected as Payee, is a document used to apply for the role of a representative payee for someone who is unable to manage their Social Security benefits. This form is essential for individuals or organizations seeking to help claimants receive and manage their benefits responsibly. If you need assistance with filling out this form, please click the button below.

Article Guide

The SSA-11 form, officially known as the Request to be Selected as Payee, is a critical document for individuals seeking to manage Social Security benefits on behalf of another person, referred to as the claimant. This form is primarily used to designate a representative payee who will receive Social Security, Supplemental Security Income (SSI), or special veterans benefits for individuals who are unable to handle their own financial affairs. Key sections of the form require the applicant to provide personal details, including their relationship to the claimant, and to explain why the claimant cannot manage their benefits independently. The form also prompts the applicant to outline their qualifications for acting as a payee, how they will stay informed about the claimant's needs, and whether the claimant has a court-appointed guardian. Information regarding the living arrangements of the claimant, the applicant's financial background, and any potential criminal history is also collected to ensure that the representative payee can responsibly manage the funds. Completing the SSA-11 form accurately is essential, as it directly impacts the well-being and financial stability of the claimant.

Ssa 11 Preview

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.

↓ Ssa 11

File Properties

Fact Name Detail
Form Purpose The SSA-11 form is used to request appointment as a representative payee for Social Security benefits on behalf of a claimant.
Eligibility Criteria Individuals applying to be a payee must demonstrate that the claimant cannot manage their own benefits, often due to age or disability.
Required Information The form requires personal information about both the claimant and the proposed payee, including Social Security numbers and living arrangements.
Legal Guardian Notification If the claimant has a court-appointed guardian or conservator, their details must be provided on the form.
Governing Laws This form is governed by federal laws related to Social Security Administration policies and procedures, specifically 42 U.S.C. § 405(j).
Submission Guidelines The completed SSA-11 form must be submitted to the local Social Security office, and it must be signed by the applicant to be considered valid.

Instructions on Utilizing Ssa 11

Filling out the SSA-11 form is an important step in the process of becoming a representative payee for someone who cannot manage their own benefits. After completing the form, it should be submitted to the Social Security Administration for review. Be sure to provide accurate information to avoid delays in processing.

  1. Begin by printing your information in ink at the top of the form, including your name, Social Security number, and the name of the claimant.
  2. Indicate whether you want the benefits paid directly to you by checking the appropriate box in item 1.
  3. In item 2, explain why the claimant is unable to manage their own benefits, including details about how they currently handle any money they receive.
  4. Describe why you would be the best representative payee in item 3. Use the Remarks section if you need more space.
  5. Answer item 4 regarding how you will know about the claimant's needs, selecting from the options provided.
  6. In item 5, indicate whether the claimant has a court-appointed guardian or conservator. If yes, provide their contact information.
  7. For item 6, specify the claimant's living situation and provide additional details about others living with them if applicable.
  8. Answer item 7 if you are applying on behalf of minor children, including information about their parents.
  9. List any relatives or friends who support the claimant in item 8, detailing their relationship and type of support.
  10. In item 9, check the box that describes your relationship to the claimant and provide additional details if necessary.
  11. Complete items 10 and 11 if you are an organization applying to be the payee, or proceed to item 12 if you are an individual.
  12. Fill out your personal information in item 12, including your name, date of birth, and Social Security number.
  13. Answer item 13 about how long you have known the claimant.
  14. Provide information in item 14 about who cares for the claimant when you are unavailable.
  15. Detail your main source of income in item 15, providing employer information if applicable.
  16. Indicate whether you give permission for a criminal background check in item 16.
  17. Answer questions in item 17 about any felony convictions and related details.
  18. Complete item 18 regarding any unsatisfied felony warrants.
  19. Indicate how long you have lived at your current address in item 19.
  20. Use the Remarks section for any additional explanations if needed.
  21. Read the information carefully before signing the form. Ensure that all provided information is accurate.
  22. Sign and date the form, providing your contact information and mailing address.
  23. If applicable, have two witnesses sign the form if it was signed by mark.

Important Facts about Ssa 11

What is the purpose of Form SSA-11?

Form SSA-11, also known as the Request to Be Selected as Payee, is used to apply for the role of a representative payee for someone who is unable to manage their Social Security or Supplemental Security Income (SSI) benefits. This form allows individuals or organizations to request to receive and manage benefits on behalf of claimants, ensuring that the funds are used appropriately for the claimant's needs.

Who can apply to be a representative payee using Form SSA-11?

Individuals such as parents, relatives, or legal guardians can apply to be a representative payee. Additionally, organizations, such as banks or social service agencies, may also apply. The applicant must demonstrate their relationship to the claimant and provide relevant details about their ability to manage the claimant's benefits responsibly.

What information is required on Form SSA-11?

The form requires various personal details, including the names and Social Security numbers of both the claimant and the applicant. Applicants must explain why the claimant is unable to manage their own benefits, describe their relationship to the claimant, and provide information about the claimant's living situation. Additional questions pertain to the applicant's financial background and any criminal history that may affect their eligibility.

How does one demonstrate the claimant's needs on Form SSA-11?

Applicants must provide a detailed explanation of why the claimant is unable to handle their own benefits. This includes a description of how the claimant currently manages any money they receive and the applicant's plan for understanding and meeting the claimant's needs. Information about the claimant's living arrangements and any support from family or friends should also be included.

What responsibilities does a representative payee have?

Once appointed, a representative payee must use the benefits received solely for the claimant's current needs or save them for future use. They are required to keep accurate records of how the funds are spent and may be held liable for any misuse of the benefits. Additionally, the payee must notify the Social Security Administration of any changes in the claimant's circumstances, such as death or changes in living arrangements.

What happens if the claimant's situation changes?

If there are changes in the claimant's circumstances, such as improved medical conditions or changes in living arrangements, the representative payee must report these changes to the Social Security Administration promptly. Failure to do so may result in the suspension of benefits or the requirement to repay any funds that were not used appropriately.

Common mistakes

Filling out the SSA-11 form can be a daunting task, and many people make common mistakes that can delay the process or lead to complications. Here are ten mistakes to watch out for when completing this important document.

First, many applicants forget to provide complete information about the claimant. It’s crucial to fill in the claimant's name and Social Security number accurately. Missing or incorrect details can lead to significant delays in processing your request.

Another frequent error is not explaining the reason why the claimant cannot manage their own benefits. This section is vital for the Social Security Administration to understand the claimant's situation. Be specific and provide examples of how the claimant currently manages their finances.

Many individuals also fail to specify their relationship to the claimant. Whether you are a parent, guardian, or another relative, clearly stating your connection helps the SSA assess your eligibility as a representative payee.

In addition, applicants often overlook the importance of answering all questions completely. Skipping questions or providing vague answers can raise red flags. Ensure that every section is addressed thoroughly, even if it means using the remarks section for additional details.

Another common mistake is not including necessary documentation. If the claimant has a legal guardian or conservator, provide their details as requested. Missing this information can complicate the approval process.

Some people mistakenly think they can use the benefits for their own needs. It’s essential to remember that funds must be used for the claimant’s current needs or saved for future use. Misusing the funds can lead to serious legal consequences.

Furthermore, applicants sometimes fail to report changes in the claimant's living situation or needs. If there are any anticipated changes, such as a move or a change in care, these should be disclosed to avoid issues down the line.

Another frequent oversight is neglecting to provide accurate contact information. Ensure that your phone number and address are correct so the SSA can reach you if needed. This is especially important for follow-up questions or clarifications.

Additionally, some applicants forget to sign and date the form. An unsigned application is considered incomplete and will not be processed. Double-check that your signature is clear and that the date is filled in correctly.

Finally, many people do not keep a copy of the completed form for their records. It’s wise to retain a copy of what you submitted. This can be helpful if there are any questions or if you need to follow up on your application.

Avoiding these common mistakes can streamline the process and increase your chances of a successful application. Take the time to review your form thoroughly before submitting it to ensure all information is accurate and complete.

Documents used along the form

When completing the SSA-11 form, several other documents may be necessary to support the application process. These documents help provide a comprehensive view of the claimant's situation and ensure that the Social Security Administration can make an informed decision regarding the appointment of a representative payee. Below is a list of commonly used forms and documents that accompany the SSA-11.

  • Form SSA-827: This form is a medical release that allows the Social Security Administration to obtain the claimant's medical records. It is essential for assessing the claimant's ability to manage their own benefits, particularly if they have a medical condition that affects their decision-making capabilities.
  • Form SSA-16: This is the application for Social Security Disability Insurance (SSDI) benefits. If the claimant is seeking benefits due to a disability, this form provides the necessary information regarding their work history and medical condition.
  • Legal Guardianship Documents: If the claimant has a court-appointed guardian, documentation proving this status may be required. These documents help establish the legal authority of the guardian to act on behalf of the claimant.
  • Proof of Relationship: Documents such as birth certificates or marriage licenses may be necessary to demonstrate the relationship between the claimant and the proposed payee. This is particularly important when the payee is a relative or spouse.

Each of these documents plays a critical role in the process of appointing a representative payee. By ensuring that all required forms are submitted, the likelihood of a smooth application process increases, ultimately benefiting the claimant and their needs.

Similar forms

  • Form SSA-16: This form is used to apply for Social Security Disability Insurance (SSDI) benefits. Like the SSA-11, it requires personal information and details about the claimant's condition, focusing on the claimant's ability to work.
  • Form SSA-827: This is a medical release form that allows the Social Security Administration to obtain medical records. Similar to the SSA-11, it emphasizes the need for accurate information regarding the claimant's health status.
  • Form SSA-1099: This document shows the total amount of Social Security benefits paid to a claimant in a given year. It serves as an official record of benefits received, much like the SSA-11 outlines the request for future benefits.
  • Form SSA-3373: This form collects information about the claimant's daily activities and limitations. It parallels the SSA-11 in assessing the claimant's ability to manage their own affairs.
  • Form SSA-60: Used to request a change in representative payee, this form is similar to the SSA-11 as it involves the management of benefits on behalf of another person.
  • Form SSA-2: This form is for applying for retirement benefits. Like the SSA-11, it requires personal information and details about the claimant's eligibility.
  • Form SSA-4: This application is for obtaining Social Security benefits for a child. It shares similarities with the SSA-11 in terms of gathering information about the claimant's living situation and support system.
  • Form SSA-5: This is an application for a child's benefits based on a parent's earnings record. It mirrors the SSA-11 by focusing on the child's needs and eligibility for benefits.
  • Form SSA-11-F6: This form is specifically for requesting a change in payee for Supplemental Security Income (SSI). Like the SSA-11, it deals with the management of benefits for individuals unable to manage their own finances.
  • Form SSA-3288: This form allows for the release of information from the Social Security Administration. It is similar to the SSA-11 in that it requires consent and details about the claimant.

Dos and Don'ts

When filling out the SSA-11 form, it is essential to approach the task with care and attention to detail. Below is a list of things you should and shouldn't do to ensure a smooth process.

  • Do read the entire form carefully before starting to fill it out.
  • Do use blue or black ink to fill out the form, as this ensures clarity.
  • Do answer all questions completely and truthfully to avoid delays.
  • Do provide additional information in the remarks section if necessary.
  • Don't leave any required fields blank; this could result in your application being returned.
  • Don't use abbreviations or shorthand; clarity is crucial.
  • Don't sign the form until you have completed all sections; your signature certifies the accuracy of your answers.
  • Don't forget to keep a copy of the completed form for your records.

Misconceptions

Understanding the SSA-11 form, which is used to request to be selected as a representative payee, is crucial for many individuals. However, several misconceptions can lead to confusion. Here are eight common misunderstandings regarding this form:

  • Only family members can be representative payees. This is not true. While family members often serve as payees, anyone who meets the criteria and can act in the best interest of the claimant can apply.
  • Once appointed, a payee can use the benefits however they want. This is incorrect. A representative payee must use the benefits solely for the claimant's needs and may be held accountable for any misuse of funds.
  • The SSA-11 form is only for minors. This misconception overlooks that the form can be used for adults who are unable to manage their own benefits due to disabilities or other reasons.
  • Payees do not need to report changes in circumstances. In reality, payees are required to report significant changes in the claimant’s situation, such as changes in living arrangements or financial status, to the Social Security Administration.
  • The process of becoming a payee is quick and easy. While it can be straightforward, the timeline varies depending on the circumstances and the thoroughness of the application.
  • Payees can receive compensation for their services. Generally, representative payees do not receive payment for their role unless they are an organization or agency specifically designated for such tasks.
  • All applications are automatically approved. This is misleading. Each application is reviewed carefully, and approval is based on the specific circumstances of the claimant and the proposed payee.
  • Once appointed, a payee cannot be changed. This is not accurate. If necessary, a new payee can be appointed, but the process must be followed to ensure the claimant's best interests are considered.

Being informed about these misconceptions can help individuals navigate the SSA-11 form process more effectively. Understanding the responsibilities and requirements associated with being a representative payee is essential for both the payee and the claimant.

Key takeaways

Filling out the SSA-11 form can be a critical step in ensuring that benefits are managed appropriately for those who cannot handle their own finances. Here are some key takeaways to keep in mind:

  • Understand the Purpose: The SSA-11 form is used to request that Social Security benefits be paid to a representative payee on behalf of someone who cannot manage their own benefits.
  • Complete All Required Sections: Ensure that all relevant sections of the form are filled out completely. Missing information can lead to delays in processing your request.
  • Provide Clear Explanations: When asked to explain why the claimant cannot manage their benefits, be specific. Detail how they currently handle their finances and why you are the best choice for a payee.
  • Be Aware of Changes: If the claimant’s living situation changes, such as moving or passing away, it is essential to notify the Social Security Administration promptly.
  • Keep Accurate Records: As a representative payee, you are responsible for using the benefits for the claimant's needs. Maintain records of how the funds are spent and be prepared to provide this information if requested.
  • Legal Responsibilities: Misuse of benefits can lead to serious consequences, including fines or imprisonment. It is crucial to understand your responsibilities and comply with all regulations surrounding the use of benefits.

By following these guidelines, you can help ensure a smooth process in managing the benefits of those who rely on your support.