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

SOCIAL SECURITY

Information for Representative Payees Who Recieve 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 govenment;

• 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 Marian 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 occured 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 (08-2009)

EF (08-2009)

Page 5

Form Ssa-11-Bk - Request To Be Selected As Payee - 2009 Page 5

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