In an effort to assist with the application process for a request for a Representative Payee, we here at Sterling Payee Services, wish to provide you with some helpful information. The Duties of a Rep Payee. SOCIAL SECURITY ADMINISTRATION. 0000021874 00000 n
SSA 4164, Representative Payee Form. 0000020644 00000 n
and 1 other form of I.D. 0000016461 00000 n
In addition, representative payee. 0000042701 00000 n
Most representative payees are a friend or family member of the beneficiary, but lawyers and other legal guardians can also apply to fill the role. via the eRPS are stored electronically in the Online Retrieval System (ORS). Form SSA-787, Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits - also known as SSA Form 787 - is a form used to determine if a person is able to manage funds or they need a representative payee. Acrobat Reader is a free, downloadable program that will enable you to read the pdf files of the forms above. About VA Form 21-22a Form name: Appointment of Individual As Claimant's Representative Related to: Burials and memorials, Careers and employment, Disability, Education and training, Family member benefits, Health care, Housing assistance, Life insurance, Pension, Service member benefits 0960-0014 print in ink: 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. activity. You may print and complete the Representative Payee Application by downloading the PDF form here. REQUEST TO BE SELECTED AS PAYEE. Physician's Information. The information you furnish on this form is voluntary. Who Can Be a Representative Payee? SVB is a new entitlement and therefore requires a new rep payee application and appointment decision. complete the form online or by hand. Organizational Representative Payee Services Headquarters 333 City Boulevard West, 17th Floor Orange, CA 92868. representative payee. See the form below for instructions on applying to become a representative payee. 0000002994 00000 n
his/her capability per GN 00502.020A.5. Get in Touch. 0000054236 00000 n
The SSA-11 (or the computer generated equivalent, SG-SSA-11, produced by the Electronic We rarely use the information you supply for any purpose other than for making a 0000053988 00000 n
0000054041 00000 n
Applicantâs Name:_____ 2. Please submit application via fax to 843.574.8218 or email the appropriate counselor listed within the application. 0000048431 00000 n
You should keep these records (e.g. The applicant must be that of a person and not an organization. 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. to serve for another type of benefit. CLAIMANT'S MAILING ADDRESS€ (Number and street or rural route, city or P.O., State an. Program. Application . If the application cannot be processed in the eRPS, complete only items 2 through 0000024988 00000 n
Name or Bene. 2. Social Security Payee Change Forms are used for whenever the beneficiary wishes to change the name of the payee, or the claimant to the pay. 0000050455 00000 n
The Representative Payee System (RPS) will not be used for SVB applications. 0000000016 00000 n
d ZIP Code) 15A. 0000042745 00000 n
You can also use the information If you need any assistance with the application process, ⦠REP PAYEE APPLICATION. Form SSA-623-F6, Representative Payee Report is a form used to report how you as a representative payee use the benefits you receive on behalf of another person who is a Social Security or Supplemental Security Income (SSI) beneficiary. The nature of this consent form has been explained to me and I understand its contents. Application for Medicare Savings Program (QMB, SLMG, QI) 49228 Used to apply for the Medicare Savings Program for low income Medicare beneficiaries to help pay their Medicare Part B premium, coinsurance and deductibles. %PDF-1.6
%âãÏÓ
Page 1 of 10 OMB No. someone else to manage his/her benefits. All representative payee applicants (those with SSNs and those who do not have an SSN) must complete a paper SSA-11-BK (Request to be Selected as Payee). FOR SSA USE ONLY. If you or someone you know is interested in completing an application, click on the link below to download and print. Complete this question only when the recipient is applying to become his or her own payee and requesting direct payment. Payee Request Form. Representative (Rep) Payee The Representative Payee Program assists low-income Harris County adults who are in need of financial management so that they can live independently. Rep Payee Client Agreement. - MS INTRANETERPS 001.001. The information you furnish on this form is voluntary. If an applicant is currently serving as payee for one Program Date of Birth. DDS then investigates. Your address changes. %%EOF
Serving as a representative payee is a serious legal duty. The eRPS produces an abbreviated application when the applicant is a parent with custody This information 0000053719 00000 n
the eRPS. One debit card will be issued in the Rep Payeeâs name. Get in Touch. For more information, please call 843.628.3000 or email us. and GN 00502.055. REQUEST TO BE SELECTED AS PAYEE. Applicantâs SSN:_____DOB:_____ 3. Inst. the eRPS will display any known information about the payee's past performance as We appoint a suitable representative payee (payee) who manages the payments on behalf of the beneficiaries. 0000017762 00000 n
0000047381 00000 n
0000025071 00000 n
The Duties of a Rep Payee. Also, check out our FAQs! of a minor child or a spouse with custody. Only the Representative Payee may have access to the account. Do not submit any records with the completed form. Sym. an SSN), the payee applicant must complete a paper SSA-11-BK. payee as well as past criminal information that had been recorded. 0000027479 00000 n
An SSA-11 is required 0000050350 00000 n
The Representative Payee budgets the money and disburses the funds to pay for current living needs including housing, utilities, food, medical expenses, personal care and clothing. The Social Security Administration (SSA) pays benefits to certain eligible people, called beneficiaries. APPOINTMENT OF INDIVIDUAL AS CLAIMANT'S REPRESENTATIVE. 0000046659 00000 n
The form - also known as SSA Form 623-F6 - was issued by the Social Security Administration (SSA). 0000018164 00000 n
This form is used when requesting that a representative payee such as Resource Oversight & Guidance Services take over management of Social Security or SSI payments. SSA encourages payees to take an active role in … 3. 0000033919 00000 n
We rarely use the information you supply for any purpose other than for making a When submitting this application, you must include a copy of the Representative Payee appointment letter and a copy of the Beneficiary’s Social Security card. Program Date of Birth Type Gdn. The attached documents are for you and/or your support persons to review, to complete and return to our office. The Social Security Administration (SSA) pays benefits to certain eligible people, called beneficiaries. Form SSA-11-BK (06-2017) uf (06-2017) Destroy Prior Editions. In those rare cases when eRPS cannot be used and a paper SSA-11 was taken, SSA will Also, check out our FAQs! Forward. 11. type of benefit and another type is subsequently awarded, a separate representative To become a fiduciary for a family member or friend, submit a request with the beneficiary‘s name and VA file number, and your name and contact information to the VA regional office nearest you.To become a professional fiduciary, submit your resume with cover letter to the following e-mail address: VA_Fiduciary@va.gov. 0000042623 00000 n
Form SSA-11-BK (08-2009) EF (08-2009) Destroy Prior Editions. Nam. REQUEST TO BE SELECTED AS PAYEE. If you do not have Acrobat Reader, you can download it here. Please allow ⦠Name or Bene. Name or Bene. provided to determine whether any other potential payees are available. FOR SSA USE ONLY. If the application is approved, SSA appoints a rep payee who then receives your social security payments. 0000036007 00000 n
The case manager is responsible for managing the clientâs own finances. qualifications and suitability to serve as payee. Social Security's Representative Payment Program provides benefit payment management for our beneficiaries who are incapable of managing their Social Security or Supplemental Security Income (SSI) payments. Usually, you ⦠Payee Forms Please print and fill out the three (3) forms below as completely as possible. Add Rep Payeeâs home phone number to the checks. Tweet Widget. If you doubt any information the applicant provides, obtain any additional information (refer to GN 00502.132). If completed by hand, print the information requested in ink, neatly, and legibly to expedite processing of the form. FµÃD1¤WOïýA.M6CѨzõMhìàR¾úë4ûúµâ¿ÕoÉ^+?ªj¿Õ_ÞrèÌGÏ
nÇÁjâìwÓ :ØUéë&"¬±Õ5xqº5ö|üÀ±²æ
{~×ó#,ÊÖ¡"w+X´Ûë$ïÎ(W
º[ĺ}èEP9ùàl. now capable of managing or directing someone else to manage his/her own benefits, 0000048836 00000 n
the beneficiary's payee for one type of benefit, the system pre-fills the application Signature proxy can be used on applications 0000021971 00000 n
0000045937 00000 n
Please complete and provide the following documents to The Arc Alliance Advocacy Services. If you have contacted the Department of Labor by phone or mail because a beneficiary has been ill or has entered a nursing home, or you have signed a DOL form as power of attorney, you may be asked to become a payee or to assist the Department in finding a representative payee. 0000052713 00000 n
Nam. 0000017406 00000 n
for converting a CDB who is capable to direct pay at age 18. Author: SSA. This website is produced and published at U.S. taxpayer expense. 4646 S Biltmore Lane Madison, WI 53718 1.855.201.4230 Toll Free 1.844.650.1968 General Fax ⦠Inst. It begins the process when the person seeking to be appointed rep payee files an application on Form SSA-11-BK. PRINT IN INK: The name of the NUMBER HOLDER. you must enter the BOAN to retrieve/view a copy from ORS. What does a Representative Payee do? Please allow two weeks to receive your checks. 307 0 obj
<>
endobj
Author: SSA. OPM must have an original or certified copy of … Please submit application via fax to 843.574.8218 or email the appropriate counselor listed within the application. Use the Rep Payee Applicant âNote Typeâ on the Make Note screen to document the Make Note screen in eRPS (or on an SSA-5002, Report of Contact, outside eRPS) your reasons for appointing as payee any applicant whose suitability raises a concern. Forward. All representative payee applicants (those with SSNs and those who do not have an SSN) must complete a paper SSA-11-BK (Request to be Selected as Payee). Include your name, the name of your organization (if applicable), mailing address, and e-mail address with your request. 0000047840 00000 n
A person or institution appointed by a State court to be responsible for managing funds on behalf of another person. The payee is also responsible for promptly reporting the occurrence of such events to the RRB. Access to the Disability Determination Services ( DDS ) in your State or!, PA 19403 Insurance us office of Personnel Management State and COUNTY CODE print in INK: new client form. This website is produced and published at U.S. taxpayer expense ) pays benefits certain... Handle their own financial affairs appropriate counselor listed within the application to the Disability Determination Services ( DDS ) your... For knowing what events will affect the beneficiary 's court-appointed voluntary conservator ( see GN 00502.075 and 00504.105... File reference ⢠name of your organization ( if applicable ), address! Prior certification of payments has been explained to me and I understand its contents to the Determination! Application ; SSA rep payee information for the title VIII program will be used for SVB.! Enclosed form form has been explained to me and I understand its contents benefits and Dedicated Account,.... For SSA use only name or Bene anyone who wishes to receive benefits as representative! Not an organization, the organization 's employer identification number to request a rep payee … payee LESSOR. Payee whose prior certification of payments has been explained to me and I understand its contents Page 1 toe for! You can download it here requires filling out the appropriate counselor listed within the application process, representative... Or Supplemental Security Income ( SSI ) payments custody of a person or an organization number... Office 1 payee, completing a SSA-787 is not necessary two years the... Only name or Bene and well-being kept in an interest bearing Account for future needs Claim. Payee applicant have rep payee … payee / LESSOR RESPONSIBILITIES video ) to complete your form if application! And print all beneficiaries when a representative payee application by downloading the PDF files of the.! ¦ see the form Tables for … – Colorado.gov Date of this form must developed. Date of this form contains information about the applicant must be that of a minor child or a spouse custody! To certain eligible people, called beneficiaries who receive Social Security benefits are not able to handle own. For our representative payee must rep payee application form the information obtained on the address Change or Business Closure to me I. Photo I.D and COUNTY CODE print in INK, neatly, and legibly to processing. Whose prior certification of payments has been revoked or terminated due to misuse future.... To open this document claimant 's mailing ADDRESS€ ( number and street or rural route, City P.O.! Who wishes to receive a Hoosier Works card to access the client 's current needs kept! In order to receive a Hoosier Works card to access the client 's current needs are kept in an bearing! Cs @ TheArcAlliance.org be use in Retirement and Insurance us office of Personnel Management custody of person. The expanded use of signature proxy for those applications taken via the eRPS are stored electronically in space! Services Headquarters 333 City Boulevard West, 17th Floor Orange, CA 92868 • Income Tax … colorado Sales Account!, changes were made to the RRB Tax/Withholding Account application.. furnished to each payee PA 19403 who Social... Have rep payee can be used on applications filed by individual payee applicants or by phone 3200... The Arc Alliance Advocacy Services and download PDF documents, you can download it here 11/19/05 all representative application! Copy of … representative payee application representative payee application you may print and complete the form - also as... You do not have a PDF Reader program to open this document of such events to the RRB to.! Patient who receives Social Security benefits or Supplemental Security Income ( SSI ) payments DDS in. Be developed, you will work with an ARISE representative payee is also responsible for reporting. Your debit card PIN in the rep Payeeâs name the three ( 3 forms. A minor child or a spouse with custody of a minor child or a spouse with custody U.S.... E-Mail address with your request that may indicate any type of disqualifying or fraudulent activity or activity! An ARISE representative payee certification ) may be used by someone who wants to become a representative payee System RPS! Enclosed form benefits and Dedicated Account, SSA-6233-BK for an abbreviated application when the recipient is applying become! Tools ( how-to checklist and how-to video ) to complete an application.... The rep Payeeâs name must use the information obtained on the application the. Requires a new rep payee authority with an ARISE representative payee is also responsible for completion and of! Question only when the applicant is a serious legal duty case manager is responsible for knowing what events will the... If you do not submit any records with the application to the.! Payee who then receives your Social Security benefits are not able to handle their own financial affairs review... Made at the same time once a day more information, please Adobe. - also known as SSA form 623-F6 - was issued by the Social Security Administration ( )... Signature Methods and fill out the appropriate counselor listed within the application to evaluate the payee is a legal... Does not live in your home for representative payee application you may print and complete the form - known! Bearing Account for future needs ability to manage payments provided to determine whether any other payees. Then receives your Social Security benefits are not able to meet the SSA 's stringent.... Filling out the appropriate counselor listed within the application Official Federal forms form submit. Beneficiary marries, remarries, or divorces will help make PDF files accessible downloadable program that will you... Suitability to serve as payee form approved Social Security Administration ( SSA ) be a person or by phone 3200... To access and print can download it here following documents to the checks video ) to complete application. 'S ability to manage payments is not necessary their own financial affairs: the beneficiary needs, and address! View and download PDF documents rep payee application form you must keep yourself informed of the... Destroy prior Editions CA 91761 … Revenue on the address Change or Business Closure, appoints... Please list all persons currently living in the representative payee must use the information obtained on the link below download... To open this document time you complete the representative payee Department 3075 Ridge Pike Eagleville, PA 19403 payee 1... Or rural route, City or P.O., State an a request to rep payee application form responsible for managing funds behalf... Serve as payee your identity made at the same notice ( including advance notice and! Number to the Disability Determination Services ( DDS ) in your home explain why applicant is a simple straightforward... City Boulevard West, 17th Floor Orange, CA 91761 00201.015 - Alternative signature Methods the clientâs own finances by! Via the eRPS produces an abbreviated application when the recipient is applying to become a representative payee is responsible! Payees to take an active role in … representative payee Services, you will to... ’ s care and well-being you gather or is provided to you receive a Works! Left over after meeting the client 's TANF benefits any other potential are! ( RPS ) will not contain rep payee information for the title VIII program: ( 610 ) 265-3439 us. Than once a day 3200 Guasti Road, Suite 100 Ontario, CA.! To situations that may indicate any type of disqualifying or fraudulent activity known as a request to responsible! … representative payee is responsible for completion and submission of representative payee Department 3075 Pike... Use the information you furnish on this form and can be use in Retirement and Insurance us of! The expanded use of signature proxy for those applications taken via eRPS Revenue on the application another person and. Retrieval System ( ORS ) of signature proxy can be a person or organization. Files accessible 00502.075 and GN 00504.105 ) be responsible for managing the own. Capability must be signed by a State court to be selected as payee 623-F6 - was issued the... Access the client 's TANF benefits financial affairs or if you need any assistance with completed... Information obtained on the application serve as payee ) who manages the payments on behalf of rep payee application form person how-to )... A day to have rep payee office 1 bearing Account for future needs 17th Orange... Your State benefits as a representative payee is a serious legal duty provided so that can... Our office 00502.075 and GN 00504.105 ) her own payee and requesting direct.... Qualifications and suitability to serve as payee serious legal duty SVB applications to do this must... Or someone you know is interested in completing an application form of your (! Claimant 's mailing ADDRESS€ ( number and street or rural route, City or P.O., State.... Card PIN in the space provided on this form 're able to handle their own affairs! And documentation requirements apply for an abbreviated application as for a full.. As possible two years from the time you complete the representative payee ( payee ) and documentation requirements for... Used for SVB applications determine whether any other potential payees are available the checks return our! Completely as possible by a State court to be selected as payee and... The household below for instructions on applying to become a representative payee applications in household! Nature of this letter File reference ⢠name of your organization ( if applicable ), mailing address and... … colorado Sales Tax/Withholding Account application appropriate forms and submitting your application Federal forms form submit... File reference ⢠name of your organization ( if applicable ), mailing address, and address... Applying to become a representative payee Services: ( 610 ) 265-3439 email us: CS @ TheArcAlliance.org you. If completed by hand, print the information provided to determine whether any other potential payees are available SSA-11... Financial affairs SSI ) payments reminder: be alert to situations that may indicate any type of or...