Ssa 11 Template

Ssa 11 Template

The SSA-11 form is a request to be appointed as a representative payee for someone receiving Social Security benefits. This form is essential for individuals who believe that the claimant cannot manage their own benefits due to various reasons, such as age or disability. If you think you’re ready to help someone in need, click the button below to start filling out the form!

Table of Contents

The SSA-11 form, also known as the Request to be Selected as Payee, plays a critical role in the Social Security Administration's (SSA) process for managing benefits for individuals who may not be able to handle their own financial affairs. This form is primarily utilized by individuals or organizations seeking to act as representative payees for claimants, including minors or those with disabilities. Applicants must provide detailed information about both themselves and the claimant, such as Social Security numbers, living arrangements, and the nature of their relationship. The form requires explanations regarding why the claimant is unable to manage their benefits and why the applicant is the best choice for this responsibility. It also includes sections for reporting any legal guardianship and for detailing how the applicant intends to meet the claimant’s needs. Furthermore, the SSA-11 form emphasizes the importance of using benefits solely for the claimant's needs, as well as the legal obligations that come with being a payee. Proper completion of this form is essential for ensuring that benefits are managed effectively and responsibly, safeguarding the financial well-being of those who rely on Social Security support.

Ssa 11 Sample

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.

Document Attributes

Fact Name Description
Form Purpose The SSA-11 form is used to request that Social Security benefits be paid to a representative payee on behalf of a claimant who cannot manage their own benefits.
Eligibility Individuals applying to be a representative payee must demonstrate that the claimant is unable to manage their benefits due to reasons such as age, disability, or other factors.
Information Required The form requires detailed information about the claimant, including their living situation, any court-appointed guardians, and the applicant's relationship to the claimant.
State-Specific Forms Some states may have additional requirements or specific forms that accompany the SSA-11, governed by state laws regarding guardianship and conservatorship.
Criminal Background Check Applicants must consent to a criminal background check as part of the application process to ensure they have no disqualifying offenses.
Usage of Funds Payments received as a representative payee must be used for the claimant's current needs or saved for future needs, with strict accountability required.
Reporting Changes Representative payees are obligated to report any significant changes in the claimant's situation, including death, changes in living arrangements, or if the claimant begins to work.
Legal Liability Failure to use the funds appropriately can result in legal liability, including the requirement to repay misused funds or penalties for misuse of benefits.

Ssa 11: Usage Instruction

Filling out the SSA-11 form is a straightforward process, but it requires attention to detail to ensure all necessary information is provided. After completing the form, it will be submitted to the Social Security Administration (SSA) for review and processing. The SSA will then determine the eligibility of the payee request based on the information provided.

  1. Begin by printing the form SSA-11 in ink.
  2. In the first section, provide your name, date of birth, and Social Security number.
  3. List the name of the claimant for whom you are requesting payee status, along with their Social Security number.
  4. Check the box if you want benefits paid directly to yourself and answer items 3, 5, 6, and 8.
  5. Explain why the claimant is unable to manage their own benefits.
  6. Describe why you would be the best representative payee. Use additional remarks if necessary.
  7. Indicate how you will stay informed about the claimant's needs, choosing from the options provided.
  8. Answer whether the claimant has a court-appointed guardian or conservator. If yes, provide their details.
  9. Provide information about the claimant’s living situation, including their address and any individuals living with them.
  10. If applying on behalf of minor children and you are not the parent, answer the questions regarding the child's natural or adoptive parent.
  11. Check the box that describes your relationship to the claimant.
  12. Indicate if the claimant owes you or your organization any money.
  13. Provide information about your employment and income sources.
  14. Answer questions regarding any criminal history and whether you have unsatisfied felony warrants.
  15. Sign the form in ink and date it.
  16. Include your contact information and address.
  17. If applicable, have two witnesses sign the form if it was signed by mark (X).

Frequently Asked Questions

  1. What is Form SSA-11?

    Form SSA-11, also known as the "Request to Be Selected as Payee," is used by individuals who wish to receive Social Security benefits on behalf of someone else, known as the claimant. This form is essential for those who believe the claimant cannot manage their benefits due to various reasons, such as age or disability.

  2. Who can fill out Form SSA-11?

    Any person or organization that wants to be appointed as a representative payee can fill out this form. This includes parents, relatives, legal guardians, or representatives from institutions. It is crucial that the individual applying understands the responsibilities involved in managing the claimant's benefits.

  3. What information is required on Form SSA-11?

    The form requires personal information about both the claimant and the proposed payee. This includes names, Social Security numbers, addresses, and details regarding the claimant's living situation. Additionally, the payee must explain why they believe the claimant cannot manage their own benefits.

  4. What is the role of a representative payee?

    A representative payee is responsible for using the benefits received for the claimant's current needs or saving them for future needs. They must keep accurate records of how the funds are used and report back to the Social Security Administration when required. If the payee misuses the funds, they may be held liable for repayment.

  5. What happens if the claimant's situation changes?

    If there are changes in the claimant's situation, such as a change in living arrangements or if they no longer need a payee, the representative payee must notify the Social Security Administration promptly. Failing to do so can result in complications with benefit payments.

  6. Can a minor child have a representative payee?

    Yes, a minor child can have a representative payee. In such cases, the form must be filled out by an adult, typically a parent or guardian. The adult must provide information about the child's living situation and any other relevant details that demonstrate the need for a payee.

  7. What if the claimant has a legal guardian?

    If the claimant has a court-appointed legal guardian, the payee must provide details about the guardian on the form. This includes the guardian's name, address, and contact information. The Social Security Administration will consider this information when determining the payee's suitability.

  8. How does the Social Security Administration verify the information?

    The Social Security Administration may conduct background checks on the proposed payee to ensure they are suitable for the role. This includes checking for any felony convictions or unsatisfied warrants. Transparency and honesty are crucial when filling out the form.

  9. What are the consequences of misusing Social Security benefits?

    Misusing Social Security benefits can lead to serious consequences, including criminal charges, fines, and imprisonment. The representative payee must use the funds strictly for the claimant's needs and keep accurate records to avoid any issues.

  10. How can I submit Form SSA-11?

    Form SSA-11 can be submitted to the local Social Security Administration office. It is advisable to keep a copy of the completed form for your records. If you have questions or need assistance, you can contact the Social Security Administration directly for guidance.

Common mistakes

Filling out the SSA-11 form can be a daunting task, and many people make mistakes that can delay the processing of their request. One common error occurs when applicants fail to provide complete information. Each section of the form is designed to gather specific details about the claimant and the proposed payee. Omitting even a single piece of information can lead to unnecessary delays. It is essential to read each question carefully and provide thorough answers.

Another frequent mistake is misunderstanding the role of the representative payee. Some applicants assume they can use the benefits for their own needs, but this is not the case. The funds must be used solely for the claimant's current needs or saved for future needs. Misusing these funds can lead to serious consequences, including legal repercussions. Therefore, it’s vital to understand the responsibilities that come with being a payee.

Many individuals also overlook the importance of explaining the claimant’s situation in detail. For instance, when asked why the claimant cannot manage their own benefits, a vague answer may not suffice. Providing a clear and comprehensive explanation can strengthen the application. The more context you provide, the better the Social Security Administration can assess the situation.

Another mistake involves failing to keep track of the claimant's living arrangements. Changes in the claimant’s living situation must be reported to the Social Security Administration. If the living arrangements are expected to change within the year, this should be clearly articulated on the form. Neglecting to mention these changes can lead to complications down the line.

Additionally, applicants often forget to include the necessary contact information. This includes not only their own contact details but also those of the claimant and any relevant guardians or conservators. Incomplete contact information can hinder communication, making it difficult for the Social Security Administration to reach out for any clarifications or updates.

Finally, many people underestimate the importance of reviewing the entire form before submission. Errors in spelling, grammar, or even minor inaccuracies can create confusion. A careful review can catch these mistakes, ensuring that the application is clear and professional. Taking the time to double-check can make a significant difference in the outcome of the request.

Documents used along the form

The SSA-11 form is a crucial document used when someone is applying to become a representative payee for Social Security benefits. Alongside this form, there are several other documents that may be required or helpful in the application process. Each of these documents serves a specific purpose and provides important information to the Social Security Administration (SSA). Below is a list of some commonly used forms and documents associated with the SSA-11.

  • SSA-16 (Application for Disability Insurance Benefits): This form is used by individuals applying for disability benefits. It collects information about the applicant’s medical condition, work history, and other relevant details necessary for determining eligibility.
  • SSA-827 (Authorization to Disclose Information to the Social Security Administration): This document allows the SSA to obtain medical records and other information from healthcare providers. It is essential for verifying the claimant's medical condition and supporting the application for benefits.
  • SSA-3373 (Function Report - Adult): This form helps the SSA assess how a claimant’s disability affects their daily life. It gathers information about the claimant's ability to perform basic tasks and engage in activities, providing a clearer picture of their functional limitations.
  • SSA-2506 (Request for Medical Evidence of Record): This request is used to obtain medical records and other evidence from healthcare providers. It is typically submitted by the SSA to gather necessary information for evaluating a disability claim.
  • Form I-864 (Affidavit of Support): If the claimant is a non-citizen, this form may be needed to demonstrate that they have adequate financial support. It shows that the claimant will not become a public charge and can help in the approval of benefits.

Understanding these forms and their purposes can significantly ease the process of applying for Social Security benefits. Each document plays a vital role in ensuring that the Social Security Administration has all the necessary information to make informed decisions regarding eligibility and benefit distribution. Being prepared with the right paperwork can help streamline the process for both the applicant and the SSA.

Similar forms

  • Form SSA-16: This form is used to apply for Social Security Disability Insurance (SSDI) benefits. Like the SSA-11, it requires detailed information about the claimant's situation and needs, focusing on their ability to work and manage finances.
  • Form SSA-827: This form is a medical release that allows the Social Security Administration to obtain medical records. Similar to the SSA-11, it involves providing information about the claimant's health and how it affects their daily life.
  • Form SSA-3368: This is the Adult Disability Report, which collects information about the claimant's work history and medical conditions. Like the SSA-11, it assesses the claimant's ability to manage their benefits.
  • Form SSA-5: The Application for a Social Security Card form collects personal information to establish eligibility for benefits. It shares the SSA-11's focus on the individual's identity and relationship to the benefits being requested.
  • Form SSA-2: This form is for applying for spouse's benefits. It similarly requires information about the claimant's marital status and relationship to the primary beneficiary, akin to the SSA-11's request for relationship details.
  • Form SSA-4: This is the Application for Child's Benefits. It also requires information about the claimant's relationship to the child and their financial needs, similar to the SSA-11's focus on the claimant's support system.
  • Form SSA-20: The Application for Widow's or Widower's Benefits is used to apply for survivor benefits. It requires information about the deceased spouse and the applicant’s relationship, much like the SSA-11's inquiry into relationships.
  • Form SSA-11-F6: This is a request for a change of representative payee. It involves similar information about the claimant's needs and the proposed payee's qualifications, paralleling the SSA-11's requirements.
  • Form SSA-21: The Work History Report collects information about the claimant’s employment history. Like the SSA-11, it assesses how the claimant's work ability affects their financial situation.

Dos and Don'ts

When filling out the SSA-11 form, it is important to adhere to specific guidelines to ensure the process goes smoothly. Here are five things you should and shouldn't do:

  • Do provide accurate information. Ensure all details, including names and Social Security numbers, are correct.
  • Don't leave any required fields blank. Each section must be completed to avoid delays.
  • Do explain the claimant's situation clearly. Provide detailed reasons why the claimant cannot manage their own benefits.
  • Don't use illegible handwriting. Fill out the form in ink and write clearly to prevent misunderstandings.
  • Do keep copies of the completed form. This will help you track what information you provided and assist in any follow-up.

Following these guidelines can help facilitate the application process and ensure that the claimant receives the necessary support in a timely manner.

Misconceptions

Here are five misconceptions about the SSA-11 form:

  • Misconception 1: The SSA-11 form is only for parents of minor children.
  • This form can be used by anyone applying to be a representative payee, not just parents. It is applicable for guardians, relatives, or other individuals who care for someone unable to manage their benefits.

  • Misconception 2: Filling out the SSA-11 form guarantees approval as a payee.
  • Submitting the form does not guarantee that the Social Security Administration will approve the request. They will review the application and determine if the applicant is suitable to manage the benefits.

  • Misconception 3: The SSA-11 form requires extensive legal knowledge to complete.
  • The form is designed to be straightforward. Most people can fill it out without needing legal expertise. Clear instructions are provided to guide applicants through the process.

  • Misconception 4: Only individuals with a financial background can be payees.
  • While financial responsibility is important, anyone who can demonstrate a genuine interest in the claimant's well-being may apply. The focus is on the ability to manage the funds for the claimant's needs.

  • Misconception 5: Once appointed, a payee cannot be changed.
  • A payee can be changed if necessary. If circumstances change, the Social Security Administration allows for a new application to appoint a different payee.

Key takeaways

Filling out the SSA-11 form requires careful attention to detail. Ensure that all sections are completed accurately to avoid delays in processing. Missing information can lead to complications in the payee appointment process.

Understanding your responsibilities as a representative payee is crucial. Payments must be used for the claimant's current needs or saved for future use. Misuse of funds can result in legal consequences, including fines or imprisonment.

Communication with the Social Security Administration (SSA) is essential. Notify them promptly of any changes in the claimant's situation, such as changes in living arrangements or if the claimant passes away. This helps maintain compliance with SSA regulations.

Documentation is key to accountability. Keep thorough records of how benefits are spent and be prepared to provide an accounting report if requested by the SSA. This ensures transparency and helps protect both the payee and the claimant.