Form Ssa-11-Bk - Request To Be Selected As Payee - 2009 Page 3

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Does the claimant owe you/your organization any money now or will he/she owe you money in the future?
YES
NO
10.
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
How long have you known the claimant?
13.
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
)
AFDC (County & State
)
Other Welfare (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.)
16.
(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 for more than one
year?
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?
Form SSA-11-BK (08-2009)
EF (08-2009)
Page 3

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