Fill in a Valid Ssa 11 Template

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?

(c) Enter the claimant's residence and mailing addresses (if different from yours).

If Yes, explain what changes are expected and when they will occur. (Use Remarks if you need more space.)

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.

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:

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

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

How long have you been employed by this employer?

(If less than 1 year, enter name and address of previous employer in Remarks.)

REMARKS: (This space may be used for explaining any answers to the questions. If you need more space, attach a separate sheet.)

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.

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.

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.