Form Ssa-11-Bk - Request To Be Selected As Payee

Do you have any unsatisfied FELONY warrants (or in jurisdictions that do not define crimes as felonies, a crime punishable by

17.

death or imprisonment exceeding 1 year) for your arrest?

YES

__________________________________________________________________________

If YES: Date of Warrant

___________________________________________________________

State where warrant was issued

18.

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.)

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.

(Month, day, year)

DATE

SIGNATURE OF APPLICANT

Telephone number(s) at which you

Signature (First name, middle initial, last name) (Write in ink)

may be contacted during the day

SIGN

HERE

Print Your Name & Title (if a representative or employee of an institution/organization)

(Number and street, Apt. No., P.O. Box, or Rural Route)

Mailing Address

City and State

Zip Code

Name of County

(Number and street, Apt. No., P.O. Box, or Rural Route)

Residence Address

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)

Form SSA-11-BK (08-2009)

EF (08-2009)

Page 4

Form Ssa-11-Bk - Request To Be Selected As Payee - 2009 Page 4

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