Form Ssa-11-Bk - Request To Be Selected As Payee - 2009
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10Form Approved
SOCIAL SECURITY ADMINISTRATION
TOE 250
OMB No. 0960-0014
FOR SSA USE ONLY
FOR SSA USE ONLY
Name or
Date of
Program
Type
Gdn.
Cus.
Inst.
Nam.
Bene. Sym.
Birth
REQUEST TO
BE SELECTED
AS PAYEE
DISTRICT OFFICE CODE
STATE AND COUNTY CODE:
PRINT IN INK:
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 4.
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 (08-2009)
EF (08-2009)
Page 1
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