Content Overview
The SSA-11 form, officially known as the Request to Be Selected as Payee, plays a crucial role in the Social Security Administration's efforts to ensure that benefits are managed appropriately for those unable to handle their own finances. This form is designed for individuals who wish to act as representative payees for claimants, such as minors or individuals with disabilities. It requires detailed information about both the claimant and the proposed payee, including their living arrangements, financial situations, and relationships. Applicants must explain why the claimant cannot manage their benefits and provide insight into how they will meet the claimant's needs. Additionally, the form addresses any existing legal guardianship and requires the payee to affirm their commitment to use the benefits solely for the claimant's needs. Ensuring that the claimant's best interests are prioritized is at the heart of this process. By completing the SSA-11 form, individuals can help secure necessary financial support for those who may be vulnerable or unable to advocate for themselves.
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Discontinue Prior Editions |
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Page 1 of 11 |
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Social Security Administration |
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OMB No. |
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FOR SSA USE ONLY |
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FOR SSA USE ONLY |
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Name or |
Program |
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Type Gdn. Cus. |
Inst. Nam. |
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Request to be |
Bene. Sym. |
Birth |
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Selected as |
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Payee |
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District Office Code |
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Print in Ink |
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State and County Code |
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The name of the NUMBER HOLDER |
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SOCIAL SECURITY NUMBER |
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The name of the PERSON(S) (if different from above) for whom you are filing (the |
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SOCIAL SECURITY NUMBER (S) |
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"claimant(s)") |
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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 5.
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 |
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Daily visits |
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Visits at least once a week. |
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By other means. Explain: |
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5. Does the claimant have a |
Yes |
No |
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If Yes, enter the legal guardian/conservator's: |
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Name: |
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Address: |
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Phone Number: |
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Title: |
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Date of Appointment: |
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Explain the circumstances of the appointment. (Use remarks if you need more space.) |
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Page 2 of 11 |
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6. (a) Where does the claimant live? |
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Alone |
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In my home (Go to (b).) |
In a public institution (Go to (c).) |
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With a relative (Go to (b).) |
In a private institution (Go to (c).) |
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With someone else (Go to (b).) |
In a nursing home (Go to (c).) |
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In a board and care facility (Go to (b).) |
In the institution I represent (Go to (c).) |
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(b) Enter the names and relationships of any other people who live with the claimant. |
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NAME |
RELATIONSHIP |
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(c) Enter the claimant's residence and mailing addresses (if different from yours).
Residence: |
Mailing: |
Telephone |
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Number |
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(d) Do you expect the claimant's living arrangements to change in the next year? |
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No |
If Yes, explain what changes are expected and when they will occur. (Use Remarks if you need more space.)
7. If you are applying on behalf of minor child(ren) and you are not the parent, |
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Is the child(ren) in foster care? |
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No |
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Does the child(ren) have a living natural or adoptive parent? |
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No |
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If yes, enter: (a) Name of parent |
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(b) Address of parent |
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(c) Telephone number |
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(d) Does the parent show interest in the child? |
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No |
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Please explain: |
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8.List the names and relationship of any (other) relatives or close friends who have provided support and/or show active interest with the claimant. Describe the type and amount of support and/or how interest is displayed.
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NAME |
ADDRESS/PHONE NO. |
RELATIONSHIP |
DESCRIBE |
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9.Check the block that describes your relationship to the claimant.
(a)Official of bank, agency or institution with responsibility for the person. Enter below which you represent:
Bank |
State, county, or local government agency |
Social Agency |
Public Official |
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Institution: |
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Federal |
State/Local |
Private |
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Private proprietary institution. Is the institution licensed under State law? |
Yes |
No |
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IF (a) ABOVE CHECKED, COMPLETE ONLY QUESTIONS 10 AND 11 AND SIGN THE FORM ON PAGE 5.
(b) Parent
(c) Spouse
(d) Other Relative - Specify
(e) Legal Representative
(f) Board and Care Home Operator
(g) Other Individual - Specify
IF (b), (c), (d), or (e) ABOVE CHECKED, GO ON TO QUESTION 12
10. Does the claimant owe you/your organization any money now or will he/she owe you money in the future? Yes No
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 |
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12. Enter: Your name |
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Date of birth |
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Social Security Number |
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Any other name you have used |
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Other SSN's you have used |
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13.How long have you known the claimant?
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) |
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Social Security benefits (Claim Number |
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Pension (describe |
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Supplemental Security Income payments (Claim Number |
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Temporary Assistance For Needy Families (TANF |
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Other State or Public Assistance (describe |
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Other (describe |
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(b) Enter your employer's name and address: |
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How long have you been employed by this employer?
(If less than 1 year, enter name and address of previous employer in Remarks.)
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Page 4 of 11 |
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16. |
Do you give Social Security permission to conduct a criminal background check on you? |
Yes |
No |
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17. |
(a) Have you ever been convicted of a felony? |
Yes |
No |
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If Yes: What was the crime? |
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On what date were you convicted? |
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What was your sentence? |
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If imprisoned, when were you released? |
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If probation was ordered, when did/will your probation end? |
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(b) Have you ever been convicted of any offense under federal or state law which resulted in imprisonment |
Yes |
No |
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for more than one year? |
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If Yes: What was the crime? |
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On what date were you convicted? |
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What was your sentence? |
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If imprisoned, when were you released? |
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If probation was ordered, when did/will your probation end? |
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18. |
Do you have any unsatisfied FELONY warrants (or in jurisdictions that do not define crimes as felonies, a crime punishable |
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by death or imprisonment exceeding 1 year) for your arrest? |
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No |
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If Yes: Date of Warrant |
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State where warrant was issued |
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How long have you lived at your current address? (Give Date MM/YY) |
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REMARKS: (This space may be used for explaining any answers to the questions. If you need more space, attach a separate sheet.)
Form |
Page 5 of 11 |
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING THIS FORM |
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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.
SIGNATURE OF APPLICANT
Signature (First name, middle initial, last name) (Write in ink)
DATE (MM/DD/YYYY)
Telephone number(s) at which you may be contacted during the day
Print Your Name & Title (if a representative or employee of an institution/organization)
Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)
City and State
ZIP Code
Name of County
Residence Address (Number and street, Apt. No., P.O. Box, or Rural Route)
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)
Address (Number and street, City, State, and ZIP Code)
Form |
Page 6 of 11 |
SOCIAL SECURITY
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 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 government;
•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 Mariana 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 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 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.
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Page 7 of 11 |
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A REMINDER TO PAYEE APPLICANTS |
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Telephone |
Before you Receive a |
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SSA Office |
Date Request |
Decision Notice |
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Received |
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Number(s) to Call |
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if you have a |
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Question or |
After you Receive a |
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Something to |
Decision Notice |
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Report |
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RECEIPT FOR YOUR REQUEST |
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Your request for Social Security benefits on behalf of the individual(s) named below has been received and will be processed as quickly as possible.
You should hear from us within days after you have given us all the information we requested. Some claims may take longer if additional information is needed.
In the meantime, if you change your address, or if there is some other change that may affect the benefits payable,
you - or someone for you - should report the change. The changes to be reported are listed on the reverse.
Always give us the claim number of the beneficiary when writing or telephoning about the claim.
If you have any questions about this application, we will be glad to help you.
BENEFICIARY
SOCIAL SECURITY CLAIM NUMBER
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 205(j), and 1631(a) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on your request for selection as a representative payee.
We will use the information to determine your eligibility to serve as a representative payee. We may also share your information for the following purposes, called routine uses:
•To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA) in the efficient administration of its programs;
•To agencies or entities who have a written agreement with SSA, to perform reviews of the representative payee program and to provide training, administrative oversight, technical assistance, and other support for the program review; and
•To third parties, contractors, or other Federal agencies, as necessary, to conduct criminal background checks and to obtain criminal history information on representative payees and representative payee applicants.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN)
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of The Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. We estimate that it will take about 11 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
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Page 8 of 11 |
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.
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Page 9 of 11 |
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A REMINDER TO PAYEE APPLICANTS |
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Telephone |
Before you Receive a |
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SSA Office |
Date Request |
Decision Notice |
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Received |
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Number(s) to Call |
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if you have a |
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Question or |
After you Receive a |
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Something to |
Decision Notice |
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Report |
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RECEIPT FOR YOUR REQUEST |
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Your request for SSI payments on behalf of the individual(s) named below has been received and will be processed as quickly as possible.
You should hear from us within days after you have given us all the information we requested. Some claims may take longer if additional information is needed.
In the meantime, if you change your address, or if there is some other change that may affect the benefits payable,
you - or someone for you - should report the change. The changes to be reported are listed on the reverse.
Always give us the claim number of the beneficiary when writing or telephoning about the claim.
If you have any questions about this application, we will be glad to help you.
BENEFICIARY
SOCIAL SECURITY CLAIM NUMBER
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 205(j), and 1631(a) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on your request for selection as a representative payee.
We will use the information to determine your eligibility to serve as a representative payee. We may also share your information for the following purposes, called routine uses:
•To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA) in the efficient administration of its programs;
•To agencies or entities who have a written agreement with SSA, to perform reviews of the representative payee program and to provide training, administrative oversight, technical assistance, and other support for the program review; and
•To third parties, contractors, or other Federal agencies, as necessary, to conduct criminal background checks and to obtain criminal history information on representative payees and representative payee applicants.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN)
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of The Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. We estimate that it will take about 11 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
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SPECIAL BENEFITS FOR WORLD WAR II VETERANS
Information for Representative Payees Who Receive Special Benefits for WW II Veterans
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 (special veterans entitlement ends the month after the claimant dies);
•the claimant returns to the United States for a calendar month or longer;
•the claimant moves or changes the place where he/she actually lives;
•the claimant receives a pension, annuity or other recurring payment (includes workers' compensation, veterans benefits or disability benefits), or the amount of the annuity changes;
•the claimant is or has been deported or removed from U.S.;
•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.
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.
BENEFITS MAY STOP IF ANY OF THE ABOVE EVENTS OCCUR. You can make your reports by telephone, mail or in person. You can contact any U.S. Embassy, Consulate, Veterans Affairs Regional Office in the Philippines or any U.S. Social Security Office.
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 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.
Form Specifications
| Fact Name | Details |
|---|---|
| Form Purpose | The SSA-11 form is used to request to be appointed as a representative payee for Social Security benefits. |
| Eligibility | Individuals applying must demonstrate that the claimant cannot manage their benefits independently. |
| Sections Included | The form includes sections for personal information, living arrangements, and relationships to the claimant. |
| Signature Requirement | The applicant must sign the form, affirming the accuracy of the provided information. |
| Witnesses | If the form is signed by mark (X), two witnesses must sign and provide their addresses. |
| Criminal Background Check | Applicants must consent to a criminal background check as part of the application process. |
| Reporting Changes | Payees must promptly report any changes in the claimant’s status or living arrangements. |
| Use of Funds | Payments received must be used for the claimant's current needs or saved for future needs. |
| State-Specific Forms | Some states may have additional forms or requirements based on local laws governing payeeship. |
| Governing Laws | Federal laws, including the Social Security Act, govern the use and responsibilities of representative payees. |
Ssa 11: Usage Guidelines
Completing the SSA-11 form is a straightforward process. This form is used to request to be appointed as a representative payee for someone who cannot manage their Social Security benefits. Follow the steps below to fill out the form accurately.
- Begin by printing your information in ink at the top of the form, including your name, Social Security number, and the name of the person for whom you are filing.
- In item 1, check the box if you are the claimant and wish to receive benefits directly. If not, skip to item 2.
- In item 2, explain why the claimant cannot manage their own benefits. Include details about how they currently handle any money they receive.
- In item 3, describe why you believe you would be the best representative payee. Use the remarks section if you need more space.
- For item 4, indicate how you will learn about the claimant's needs, such as living together or visiting regularly.
- In item 5, answer whether the claimant has a court-appointed guardian or conservator. If yes, provide their details.
- In item 6(a), indicate where the claimant lives. Follow up with item 6(b) to list anyone else living with them.
- In item 6(c), provide the claimant's residence and mailing addresses. Include their telephone number.
- In item 7, if you are applying on behalf of a minor child and are not the parent, answer the questions regarding the child's living parents.
- In item 8, list any relatives or close friends who support the claimant, detailing the nature of their support.
- In item 9, check the box that describes your relationship to the claimant. If you are a parent, spouse, or other relative, continue to item 12.
- In item 10, indicate if the claimant owes you or your organization any money, providing details if applicable.
- For item 11(a), if applying as an institution, enter the institution's name and EIN. If applying as an individual, proceed to item 12.
- In item 12, fill in your name, date of birth, Social Security number, and any other names or SSNs you have used.
- In item 13, state how long you have known the claimant.
- In item 14, explain who takes care of the claimant when you are unavailable, including their relationship to the claimant.
- In item 15, provide information about your income source and your employer's details if applicable.
- In item 16, indicate whether you give permission for a criminal background check.
- In items 17 and 18, answer questions regarding any felony convictions or warrants against you.
- Complete the signature section at the bottom of page 4, ensuring you sign in ink and provide your contact information.
- If you signed by mark (X), two witnesses must sign and provide their addresses.
After completing the form, review all entries for accuracy. Ensure that all required sections are filled out before submitting the form to the Social Security Administration. This will help facilitate the process of your request to be appointed as a representative payee.
Your Questions, Answered
What is the SSA-11 form used for?
The SSA-11 form, also known as the Request to be Selected as Payee, is used to request that Social Security benefits be paid to a representative payee instead of the claimant. This form is typically completed when the claimant is unable to manage their benefits due to reasons such as being a minor or having a disability. The representative payee is responsible for using the benefits for the claimant's current needs and saving any unneeded funds for future use.
Who can apply to be a representative payee?
Any individual or organization can apply to be a representative payee, provided they meet certain criteria. This includes parents, relatives, legal guardians, and officials from institutions or agencies that care for the claimant. The applicant must demonstrate their ability to manage the claimant's benefits responsibly and act in the best interest of the claimant.
What information do I need to provide on the SSA-11 form?
The form requires various pieces of information, including the claimant's personal details, living arrangements, and the relationship between the claimant and the applicant. You will also need to explain why the claimant cannot manage their own benefits and why you would be the best representative payee. Additional details about your own financial situation and any criminal history may also be required.
How does the Social Security Administration determine if I am suitable to be a payee?
The Social Security Administration (SSA) reviews the information provided on the SSA-11 form to assess your suitability. They will consider your relationship with the claimant, your ability to manage their benefits, and any relevant background information, including financial stability and criminal history. The SSA aims to ensure that the claimant's needs will be met and that their benefits will be used appropriately.
What are my responsibilities as a representative payee?
As a representative payee, you are responsible for using the benefits for the claimant's current needs and saving any unneeded funds for future use. You must keep accurate records of how the benefits are spent and file an accounting report when requested by the SSA. Additionally, you must notify the SSA of any changes in the claimant's situation, such as changes in living arrangements or if the claimant passes away.
What happens if I misuse the benefits?
If you misuse the benefits or fail to fulfill your responsibilities as a representative payee, you may be held liable for repayment of any funds misused. The SSA can take legal action against you, which may include fines or imprisonment. It is essential to manage the benefits responsibly and adhere to all guidelines provided by the SSA.
How can I contact the Social Security Administration for assistance with the SSA-11 form?
You can contact the Social Security Administration by phone, mail, or in person at your local office. They can provide guidance on completing the SSA-11 form and answer any questions you may have about the process. It is advisable to reach out for assistance if you need help understanding the requirements or filling out the form.
Common mistakes
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Incomplete Information: Failing to fill out all required sections can lead to delays. Ensure every applicable question is answered fully.
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Incorrect Claimant Information: Providing inaccurate details about the claimant, such as their Social Security number or date of birth, can result in processing errors. Double-check this information before submission.
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Neglecting to Explain Circumstances: Not adequately explaining why the claimant cannot manage their own benefits can weaken the application. Provide clear and thorough reasons in the designated sections.
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Missing Signatures: Forgetting to sign the form or have required witnesses sign can invalidate the application. Ensure all necessary signatures are present before submission.
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Failure to Update Changes: Not notifying the Social Security Administration of any changes in the claimant’s circumstances, such as a change in living arrangements, can lead to complications. Keep the SSA informed of any relevant updates.
Documents used along the form
When applying to be a representative payee using the SSA-11 form, you may also need to prepare additional documents to support your application or provide necessary information. Here are five common forms and documents that are often used alongside the SSA-11:
- Form SSA-827: This is the Authorization to Disclose Information to the Social Security Administration. It allows the SSA to obtain medical records and other information about the claimant, which can be crucial for assessing their eligibility for benefits.
- Form SSA-16: This is the Application for Disability Insurance Benefits. If the claimant is applying for disability benefits, this form provides detailed information about their work history and medical condition.
- Form SSA-3373: Known as the Function Report, this document gathers information about the claimant's daily activities and limitations. It helps the SSA understand how the claimant's condition affects their ability to function in everyday life.
- Form SSA-541: This is the Statement of Death by Funeral Director. If the claimant has passed away, this form is used to report the death and may be necessary for closing out their benefits.
- Proof of Relationship Documentation: This could include birth certificates, marriage licenses, or adoption papers. Such documents help establish the relationship between the claimant and the payee, which is essential for the SSA's review process.
Gathering these documents can streamline the application process and help ensure that the needs of the claimant are met promptly. Make sure to review each document carefully and provide accurate information to avoid delays.
Similar forms
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Form SSA-827: This form is used to authorize the release of medical information to the Social Security Administration. Similar to the SSA-11 form, it requires detailed personal information and is essential for determining eligibility for benefits based on disability. Both forms involve the claimant and require signatures to validate the information provided.
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Form SSA-16: This is the application for Social Security Disability Insurance benefits. Like the SSA-11, it gathers information about the claimant's condition and ability to manage their own affairs. Both forms are aimed at assessing the claimant's needs and eligibility for benefits, though SSA-16 focuses specifically on disability claims.
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Form SSA-4: This form is used to apply for Social Security benefits on behalf of a child. It shares similarities with the SSA-11 in that both require information about the claimant's living situation and the applicant's relationship to the claimant. Each form aims to establish eligibility for benefits while considering the claimant's best interests.
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Form SSA-21: This form is for the Supplemental Security Income (SSI) application. It is similar to the SSA-11 as both forms require comprehensive information about the claimant's financial and living situation. The SSA-21 focuses on income and resources, while the SSA-11 emphasizes the need for a representative payee.
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Form SSA-11-BK: This is essentially the same form as the SSA-11 but is specifically the paper version used for requests to be selected as a payee. It serves the same purpose, gathering information about the claimant's ability to manage benefits and the applicant's qualifications to act as a payee.
Dos and Don'ts
When filling out the SSA-11 form, there are important steps to follow. Here’s a list of things you should and shouldn’t do:
- Do: Read the entire form carefully before starting.
- Do: Use black or blue ink to fill out the form.
- Do: Provide accurate and complete information about the claimant.
- Do: Sign and date the form where required.
- Don’t: Leave any required fields blank.
- Don’t: Submit the form without reviewing it for errors.
Following these guidelines will help ensure that the application process goes smoothly. Properly completing the SSA-11 form can make a significant difference in the timely processing of benefits.
Misconceptions
Understanding the SSA-11 form can be challenging. Here are ten common misconceptions about this important document, along with clarifications to help you navigate the process.
- Misconception 1: The SSA-11 form is only for parents.
- Misconception 2: You cannot be a payee if you have a criminal record.
- Misconception 3: You must live with the claimant to be a payee.
- Misconception 4: You can use the benefits for your own expenses.
- Misconception 5: The SSA-11 form is the only document needed to become a payee.
- Misconception 6: You can change payees easily.
- Misconception 7: You can apply for the SSA-11 form online.
- Misconception 8: There is no need to report changes in the claimant's situation.
- Misconception 9: You can be paid for acting as a payee.
- Misconception 10: The SSA-11 form is only for Social Security benefits.
This form can be completed by anyone who wishes to act as a representative payee, not just parents. Guardians, relatives, or even institutions can apply.
While a criminal record may raise concerns, it does not automatically disqualify you from being a payee. The SSA will review your history and make a determination.
Living with the claimant is not a requirement. You can serve as a payee even if you reside separately, as long as you can meet the claimant's needs.
Benefits must be used solely for the claimant's needs. Misusing these funds can lead to legal consequences.
Additional documentation may be required, such as proof of your relationship to the claimant or financial records. Always check for specific requirements.
Changing a payee is a formal process that requires the SSA's approval. You cannot simply decide to switch payees without following the proper steps.
As of now, the SSA-11 form must be completed in paper format and submitted by mail or in person. Online applications are not available.
It is crucial to report any changes, such as the claimant's death or changes in living arrangements, to the SSA promptly. Failure to do so can result in overpayments.
While you can be reimbursed for certain expenses, you cannot receive payment for your role as a payee. The position is meant to serve the claimant's best interests.
This form is applicable for various benefits, including Supplemental Security Income (SSI) and special veterans benefits. It is not limited to just Social Security.
Being informed about these misconceptions can help you navigate the SSA-11 form more effectively. Understanding the requirements and responsibilities involved is essential for serving as a representative payee.
Key takeaways
Key Takeaways for Filling Out and Using the SSA-11 Form
- Ensure accurate information: Fill out the form completely and accurately, including names, addresses, and Social Security numbers. Any errors can delay processing.
- Understand your role: As a representative payee, you are responsible for managing the benefits on behalf of the claimant. This includes using the funds for their current needs.
- Be prepared to explain circumstances: Provide clear explanations regarding why the claimant cannot manage their benefits independently. Detail how you will meet their needs.
- Notify promptly of changes: If there are changes in the claimant's living situation, health status, or your ability to serve as payee, inform the Social Security Administration immediately.
- Keep thorough records: Maintain documentation of how benefits are used, as you may be required to provide an accounting to the Social Security Administration.
- Be aware of legal responsibilities: Misuse of funds can lead to legal consequences, including repayment obligations and potential criminal charges. Always act in the best interest of the claimant.