Form SSA-6234 Representative Payee Report (Organizations)

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Social Security Administration
~e~resentativ
Payee
e
Report

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We must regularly review how representative payees used the benefib they

Why YOU
Received
This Form

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received on behalf of the Social Security and/or Supplemental Security Inmme (SSI)
beneficiaries. We do thi. to emure the benefltn are used properly.
U'hen you or your organization waa appinted representative payee, you were
informed of the dutios and responsibilities of a representative payee, including
keeping recotds and reporbing on the use of benefits. You should w e these record8 to
answer the questions on the encloaed reporting form. You m w t complete this form
if you received any Social Security andlor SSI paymentti durina the 12-month report
pinod shown on ihe form. You m k t also cornplebe the fbm ifyou wish t o continus
ts receive oavmenta for another emo on. It is called Renreeentative W v e ~
Rewrt.

You should keep thest! reeurds le.g., bank utatemenb end canceled ch&, receipts
for writ, cte.) for two years from the time you complete the form. Do not submit any
orzepnlre
we a"-con^ you.

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What YOU Need
To Do

Please read the instructions below before completing the form. Then complete
the form a n d a n d it to us in t h e enclosed envelope within 90 d a y s

General
Instructions

WJ help us process your r e p d , pleose follow these instmctions:
1. Use black ink a t a #z pencil.
2. Keel, your numbers and T s * inaide the boxes.
8. Do not use d o k aigns.
4. Show money amounts in dollars only. Do not &howcenta
For example, ahow $1,540.70 like thia:
DOLLAR AMOUNT

5. Use the REMAR& ~ectiox~
on the hack uf the i o m to provide addition01

information BB requeetd.
6 . Review the payee mailing addresa and c o m t if necessary.
7. Print mlatimhip or job title in the boxes provided wing
For example, print 'Admhktxator" like this.

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8. Be ~ u r you,
e
the representative payee, sign t h e form.

Some
Definitions
To Help You

Benefite -The Soelal Becunty and/or S91money that you receive.
Payee -You The pereon or organizahon (e.g., instatutron, agency) that receives
Soclal Security and/or SSI beneGtY for someone else
BmeAciary -The p e w n for whom you receivo Social Socunty and/or SSI benefits
Legal Guardian The w o n or organination appainted by a State court ts
manage the &airs of a bene5mq.
h e Money collected frum a beneficiary for payea m guardinship services

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Report Period The 12-month period shown on the *port for which you munt
account for t h benefits
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yau received.
Tdol Accountable Amount The amount of benefits paid lo you during the
report period ploe any amount you reported as saved on last yoar's report.

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FORM SSA-82&COCR-SM (12-2004)

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CvnHnued on the Reversa

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HOW TO FILL OUT THJ3 FORM
QUESTION 1 Beneficiary

Place an "X" in the "YES" box if the beneficiary continued to live
alone, or with the same person, or in the same institution during
the entire report period. Place an X in the "NO" box if different
people or different institutions took care of the beneficiary dwing
any part of the report period. Explain the change and provide the
beneficiarfa current address under REMARKS.

Custody

Changes

QUESTION 2 Accounting
For Benefits

The total accountable amount includes the benefits you received
during the report period plus any benefits you reported as saved on
last year's report.

A. Who Deuded
How Benefits

Place an "X" in the "YES" box ifyou (the payee) decided how the
benefits were ~ p nort saved. Place an 'X" in the 'NO" box if the
beneficiary or gomeone else decided how to use the mObey, and
explain under R
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Were Used?
B. Did You
Charge A Fee?

And
How Much Did
You Collect?

Place an rC" in the "YES" bax ifyou charged the beneficiary a fee
for payee or guardianship services you provided during the report
show the total amount of benefit3 you collected from the
period
beneficiary. If you did not charge the beneficiary a fee, place an "X"
in the "NO"bax and g ~ &2.C. below.

C. Food and
Housing

Show the total amount of benefits spent for food and housing for the
beneficiary during the report period.

D. Personal

Show the total amount of benefits spent on clothing, medicavdental
care,
...fand
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recreational
--.. items
-. like to s, movies, cameras,
s education
raiiiis:CaX a a lunarv muululne a l d 8 d l ~ E
nh'&
~~FenOZ
.period
If the &;ciary
li& in an institu20n or oiher care
facility. you should spend a t least $360 a year for the beneficiary's
personnl needs. If you spent leas than $361),explain under

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E. Unused
Benefits

Show the total amount of benefits you have saved for the beneficiary
at the end of the report period, including any interest earned. Show
zeroes if you did not save any of the benefits.

FORM 88AaasCOCRSM (12-2004)

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QUESTION 3 Savings
Information

Answer this question if you showed an a n i ~ u nin
t 2.E.

k Type Of
Account

Place an "X" in the box which shows how you are saving the benefite.
Place an X in the 'Other" box if your method of saving the benefits
is not listed.

B. Account

Place an "X" in the box which most accurately describes the wording
of the account title you have on the beneficid8 savings.Place an
'24" in the "Other" box if the account title is differentor if you have
not placed the savings in any type of account.

Title

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QUESTION 4
Other Savingd
Account Titles

Answer this question only if you checked "OTHER" in 3A. or 3.B.

k TypeOf
Account

Indicate whether the saved benefits are in caeh, Treasury Bills, or
some other investment such as mutual funds. For mutual funds,
be sure to ghow the name of the fund in your reeponse (e.g., "XYZ
Growth" mutual fund).

B. Title Of
Account

Show the title of the account if the savings are in an account or
other investment. Show "none" if the savings are not in nn account
or investment.

5. Payee's

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Sign your name in this h k .If the payee is an organization, a n
uuthvrhd p c m m e a i g n the f4lnt. 'i.hisindudes the signature of
- - ---those employees desigmted to cornplate tbe report on behalf of the
payee.

Ehow your relationship to the beneficiary. If you are the beneficiary'e
court-appointed legat guardinn, show "legal guardianJ~f you
represent an organization, ahow your job title (e.g., administrator,
bookkeeper, etc.).

FORM BBA4TXM-OCRBM (12-20043

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Your ResponsibilitiesAs
Representative Payee
Wc appreciate your serviced as representative
payee. A6 payee, you must use the Social
Secunty and/or SSI benefits you receive for the
care and well being of the beneficiary. You need
to know the beneficiary's needs so that you can
use the money properly.

In addition to reporting on the use of benefits,
you must report any changes which may affect
the beneficiary's eligibility for benefits, or
the payment amount. You should report the
changes as soon as possible by calling SSA a t
1-800-772-1213,or by calling or writing your
local SSA office. For example, you must tell us
if the beneficiary:
dies,
moves (especially if hefshe enters or leaves
a hospital or other institution),
marries,
st& or stops working,
is imprisoned,
is adopted,
no longer needs a payee, or
you are no longer responsible for the
beneficiary.
If you are payee for a child receiving SSI
benefits, we may ask you fox proof that the
child is receiving medical treatment for
hi.s/her disabling condition. We may ask for
this information a t the time we review the
child's case. If we do ask for this information,
you must give it to us.

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e Privacy Act And Paperwork
Act Statements
We are required by sections 205Cj) and
1631(a)of the Social Security Act to ask you
to complete this report.The information
you provide enables SSA to account for the
beneficiary's payments, and enaures that
beneficiary needs are bebg met.If you do not
complete and return this report, we may not
be able to continue sending the beneficiary's

The law sometimes roquires us to give out
the facts on this form without your consent.
The information must be released to another
person or government agency if Fadera1 law
requitee the information for research and
audits inorder to administer or improve our
representative payee program.
We may also use the information you give us
when we match records by computer. Matching
programs compare our records with those
of other Federal, State, or local government
agencies. Many agencies may use matching
p r o g r m to h d or prove that a person
qualifies for benefits paid by the Federul
government. The law allows us to do this even
if you do not agree to it. Explanations about
these snd other reaeons w h y information
you provide u s may be used or given out ate
available in Social Security offices. If you want
to learn more about this, contact nny Social
Security of8ce.
This information collection meets the
requirements of44 U.S.C. 83507, as amended
by section 2 of the
You do not need to answer these
quodons unleea we display a valid Office of
Management and Budget control number. We
estimate that it will take about 16 minutes
to read the instructions, gather the necessary
facts, and answer the questions. You m y send
comments on our time estimate above to: SSA,
1338 Anna Building, Baltimore, MD 2 1235.
Send gnLY commente ~ l d n tog our time
eetimate to thie addre~e,not the completed

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Form.
If You-Haw Anp Questions
If you have any questions, please call UR at
1-800-772-1213.We can answer most questions
over the phone. If you prefer to v S t one of our
offices, please uee the 800 number and we will
give you the address and telephone number of
the office nearest you. Please take this report
f ~ s ac*' '
with you if you visit an office.P O
-SIT<

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Gaee
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OF m b e r
This report is about the nefits you received between
and
for
the beneficiary,
Please read the enclosed instructions
b e h e completing this f rm to help you answer each question.

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with the aarne person, or in the ssme
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furrent addreea in REMARKS an

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Total Accountable Amo

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YES

NO

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ecide how the 8
waa spent or saved?
in REMARKS on the back afthis form.

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Did yqu (the pydl charge the beneficiary a fee for payw or
luuduniihip
you pmided between
and

NO

YES

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&d you enllact fmm the beneficiary

and

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How much of the
food and housing

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and
ed on laat year's report.

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If NO,p\ease
the back ofthis fotm.

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did y w spend for the beneficky's
and
? did you spond an other things for the
education, msdieal and dmtal expenses.

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did you save Tor the
? If nme, ehow a e m .

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B. TITLE OF ACCOUNT
aNW

I h l a m umdar
any a-mpeny
updfmibad tha

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&at 1have -bed all the hriom~tion
on W

e form, and on
andAtistaue~dwreecttothebe&ofmy lmoaledge.1
give4 a trbe M mleleadhg stphment about a materid
&so,mmmitaaecimeapdmaybernntb

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