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

SUPPLEMENTAL SECURITY INCOME

Information for Representative Payees Who Receive 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 or any member of the claimant's household DIES (SSI eligibility ends with the month in which the

claimant dies);

•

the claimant's HOUSEHOLD CHANGES (someone moves in/out of the place where the claimant lives);

•

the claimant LEAVES THE U.S. (the 50 states, the District of Columbia, and the Northern Mariana Islands) for 30

consecutive days or more;

•

the claimant MOVES or otherwise changes the place where he/she actually lives (including adoption, and

whereabouts unknown);

•

the claimant is ADMITTED TO A HOSPITAL, skilled nursing facility, nursing home, intermediate care facility, or

other institution;

•

the INCOME of the claimant or anyone in the claimant's household CHANGES (this includes income paid by

an organization or employer, as well as monetary benefits from other sources);

•

the RESOURCES of the claimant or anyone in the claimant's household CHANGES (this includes when conserved

funds reach over $2,000);

•

the claimant or anyone in the claimant's household MARRIES;

•

the marriage of the claimant or anyone in the claimant's household ends in DIVORCE or ANNULMENT;

•

the claimant SEPARATES from his/her spouse;

•

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) issued for his/her arrest;

•

the claimant is violating a condition of probation or parole under State or Federal law.

IF THE CLAIMANT IS RECEIVING PAYMENTS DUE TO DISABILITY OR BLINDNESS, YOU MUST ALSO REPORT IF:

•

the claimant's MEDICAL CONDITION IMPROVES;

•

the claimant GOES TO WORK;

•

the claimant's VISION IMPROVES, if the claimant is entitled due to blindness;

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 an 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.

PAYMENT 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. (Savings are considered

resources and may affect the claimant's eligibility to payment.);

•

you may be held liable for repayment of any payments not used for the claimant's needs or of any overpayment

that occurred 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 a correct accounting;

•

to let us know as soon as you know you are unable to continue as representative payee or the claimant no longer

needs a payee;

•

you will be asked to help in periodically redetermining the claimant's continued eligibility or payment. You will

need to keep evidence to help us with the redetermination (e.g., evidence of income and living arrangements).

•

you may be required to obtain medical treatment for the claimant's disabling condition if he/she is eligible under

the childhood disability provision.

Keep in mind that payments 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 7

Form Ssa-11-Bk - Request To Be Selected As Payee - 2009 Page 7

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