Form SSA-788 Statement of Care and Responsibility for Beneficiary

Social Security Administration

Form Approved
0MB No. 0960-0109

TOE 250

STATEMENT OF CARE AND RESPONSIBILITY FOR BENEFICIARY
In replying, use this address:
SOCIAL SECURITY ADMINISTRATION

NAME AND ADDRESS OF CUSTODIAN

TELEPHONE NUMBER
DATE
SSA CONTACT

NAME OF WAGE EARNER OR SELF-EMPLOYED PERSON

SOCIAL SECURITY NUMBER

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IDENTIFYING INFORMATION
(If different from patient)

BENEFICIARY NAME

APPLICANT'S NAME AND ADDRESS

BENEFICIARY SOCIAL SECURITY NUMBER
APPLICANT'S RELATIONSHIP TO BENEFICIARY

D

YOUR HELP IS NEEDED
The applicant shown above has applied to be appointed representative payee for the above beneficiary. We need you to
complete this form and return it to us in the enclosed envelope. The information you provide will help us decide if we should pay
this person directly or if he or she needs a representative payee to handle funds. If a representative payee is needed, you will
help us to determine the responsibility assumed by the applicant for the beneficiary's well-being. Thank you for your help.
1. DATE BENEFICIARY BEGAN LIVING WITH YOU
(month/day/year)

HOW LONG WILL
BENEFICIARY LIVE
WITH YOU?

REASON BENEFICIARY DOES NOT LIVE
WITH THE APPLICANT

2. If the beneficiary is not living with you, where and with whom is the beneficiary living and when did he or she leave your care?

3. Do you believe the beneficiary is capable of managing or directing the management of benefits in his or her own best interest?
By capable we mean the beneficiary:
• Is able to understand and act on the ordinary affairs of life, such as providing food, housing, clothing, etc., and
• Is able, in spite of physical impairments, to manage funds or direct others how to manage them.
Yes
No

D

If "No" or "Unsure," please provide a brief explanation.

Form SSA-788 (01-2015) UF (01-2015)
Destroy Prior Editions

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D Unsure

4. Please show the approximate amount you charge each month for the beneficiary's room,
board, and care

PER MONTH

$

5. Does (or did) any agency, including the applicant, pay toward the cost of the beneficiary's care and maintenance?
DYes 0 No
If "Yes" please supply the information requested below.

AMOUNT CONTRIBUTED

HOW OFTEN CONTRIBUTIONS ARE MADE

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NAME AND ADDRESS

6. How often and when was the last time the applicant did any of the things shown below for the beneficiary?

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How often?
Last Time?

SENDS OTHER GIFTS

SENDS CLOTHING

VISIT

WRITES LETTERS

7. L1st the names and relat1onsh1p of any other relat1ves or close fnends who have prov1ded support and /or show interest in the
claimant. Describe the type and amount of support and/or how interest is displayed.
RELATIONSHIP

ADDRESS/PHONE NO.

D

NAME

8. Does the beneficiary have any unmet personal needs at this time?

0

Yes

0

SUPPORT/INTEREST

No

If "Yes," please list the needs. ·

9. In emergency situations, where the beneficiary needs surgery, becomes seriously ill, etc., who would you notify?

NAME

~ADDRESS

10. Does the applicant give you any instructions for the care of the beneficiary?

D Yes D No

If "Yes," explain what those instructions are, how often they are given, and what the applicant does to see that they are
carried out.

Form SSA-788 (01-2015) UF (01-2015)

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Privacy Act Statement
Collection and Use of Personal Information

See revised Privacy Act and
authorize us to collect this information.
We will use
the
PRA Statements
attached.

Sections 205(a) and 205U) of the Social Security Act, as amended,
information you provide to help us establish your suitability to serve as a representative payee.

Furnishing us this information is voluntary. However, failing to provide us with all or part of the information could prevent us from
making a decision to select you as a representative payee.
We rarely use the information you supply for any purpose other than for establishing payee suitability. We may also disclose
information to another person or to another agency in accordance with approved routine uses, which include but are not limited to
the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or
coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government
Accountability Office and Department of Veterans' Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and
local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of
Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).

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We may also use the information you provide in computer matching programs. Matching programs compare our records with
records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to
establish or verify a person's eligibility for federally-funded or administered benefit programs and for repayment of payments or
delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Records Notice entitled, Master Representative
Payee File, 60-0222. This notice, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.

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 10 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 21235-6401.

D

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. I understand that anyone who knowingly
gives a false or misleading statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be sent to prison, or may face other penalties, or both.
SIGNATURE OF PERSON MAKING STATE ME NT

SIGNATURE (First name, middle initial, last name) (Write in ink)

DATE (Month, day, year)

SIGN
HERE

TELEPHONE NUMBER (Include area code)

MAILING ADDRESS (Number and street, Apt. No., P.O. Box, or Rural Route)
CITY AND STATE

NAME OF COUNTY (IF ANY)

ZIP CODE

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the individual must sign below, giving their full address.
1. SIGNATURE OF WITNESS
ADDRESS (No. & Street, City, State, and ZIP Code)

Form SSA-788 (01-2015) UF (01-2015)

2. SIGNATURE OF WITNESS
ADDRESS (No. & Street, City, State, and ZIP Code)

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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 SSA-788 (01-2015) UF (01-2015)

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SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205 and 1631 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 a timely and accurate decision on the applicant’s suitability to
serve as representative payee for the beneficiary.
We will use the information you provide to verify the payee applicant’s statements of concern
and to identify other potential payees. We may also share the information for the following
purposes, called routine uses:


To student volunteers, persons working under a personal contract, and other workers who
technically do not have the status of Federal employees, when they are performing work
for SSA, as authorized by law, and they need access to personally identifiable
information in SSA records to perform their assigned agency functions; and



To contractors and other Federal Agencies, as necessary for the purpose of assisting the
SSA in the efficient administration of its programs.

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 Notice
(SORN) 60-0222, entitled Master Representative Payee File, as published in the Federal Register
on April 22, 2013, at 78 FR 23811. Additional information and a full listing of all our SORNs
are available on our website at https://www.ssa.gov/privacy/.

7/30/2018 2:08 PM

SSA will insert the following revised PRA Statement into the form as soon
as possible:

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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
10 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 21235-6401.