Form Ssa-788-F4 - Statement Of Care And Responsibility For Beneficiary
ADVERTISEMENT
1
2
3
4Form Approved
SOCIAL SECURITY ADMINISTRATION
TOE 250
OMB No. 0960-0109
STATEMENT OF CARE AND RESPONSIBILITY FOR BENEFICIARY
In replying, use this address:
NAME AND ADDRESS OF CUSTODIAN
SOCIAL SECURITY ADMINISTRATION
TELEPHONE NUMBER
DATE
SSA CONTACT
Sections 205(a) and 205(j) of the Social Security Act allow us to ask for the
IDENTIFYING INFORMATION
information on this form. Although responses to these questions are voluntary, the
(if different from patient)
information you provide is needed to establish an applicant's suitability to serve as
representative payee.
NAME OF WAGE EARNER OR SELF-EMPLOYED
PERSON
We may also use the information you give us when we match records by computer.
Matching programs compare our records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove
that a person qualifies for benefits paid by the Federal government. The law allows
us to do this even if you do not agree to it.
SOCIAL SECURITY NUMBER
Explanations about these and other reasons why information you provide us may be
used or given out are available in Social Security offices. If you want to learn more
about this, contact any Social Security office.
APPLICANT'S NAME AND ADDRESS
BENEFICIARY NAME
BENEFICIARY SOCIAL SECURITY NUMBER
APPLICANT'S RELATIONSHIP TO BENEFICIARY
YOUR HELP IS NEEDED
The applicant shown above has applied to be appointed representative payee for the above beneficiary. We need
you to complete this form and return it to us in the enclosed envelope. The information you provide will help us
decide if we should pay this person directly or if he or she needs a representative payee to handle funds. If a
representative payee is needed, you will help us to determine the responsibility assumed by the applicant for the
beneficiary's well-being. Thank you for your help.
HOW LONG WILL
REASON BENEFICIARY DOES NOT LIVE WITH THE APPLICANT
1. DATE BENEFICIARY BEGAN LIVING
WITH YOU
BENEFICIARY LIVE WITH
(month/day/year)
YOU?
2. If the beneficiary is not living with you, where and with whom is the beneficiary living and when did he or she leave your care?
3. Do you believe the beneficiary is capable of managing or directing the management of benefits in his or her own best interest?
By capable we mean the beneficiary:
• Is able to understand and act on the ordinary affairs of life, such as
providing for own food, housing, clothing, etc., and
• Is able, in spite of physical impairments, to manage funds or direct
YES
NO
UNSURE
others how to manage them.
If ''NO'' or ''Unsure," please provide a brief explanation.
Form SSA-788-F4 (09-2007) EF (09-2007) Destroy Prior Editions
Formerly SSA-788
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form In-0580 - Quarterly Statement Of Premiums And Fees For Taxation - Life And Accident And Health Companies - 2010
Financial
Form N-346a - Certified Statement Of Research And Development Costs Incurred By A Qualified High Technology Business (qhtb) And Claim Of The Tax Credit For Research Activities - 2015
Financial
Form In-0578 - Statement Of Premiums And Fees For Taxation - Companies Other Than Life - Tennessee Department Of Commerce And Insurance - 2002
Financial
Related Categories
Parent category: Legal