Form SSA-639 Expanded Monitoring Site Review Beneficiary Review Form

Form Approved
OMB No. 0960-0633

Social Security Administration

Expanded Monitoring Program
Site Review - Beneficiary Interview Form
Beneficiary Name

Beneficiary Telephone Number

Beneficiary SSN/Claim Number

Beneficiary Residence Address

Payee Name

Payee Address

Ask the beneficiary (or, if the beneficiary cannot respond, the custodian or other caregiver) the following questions:
1. Has the payee been paying your bills on time?

Yes

No

If No, explain:

2. Is the payee responsive to your needs?

Yes

No

If No, explain:

3. Have you ever asked the payee for money for a specific purchase and been denied?

Yes

No

If Yes, what was it that you needed and why did the payee tell you you could not have it?

4. Does the payee ever give you any money, including cash, money orders, checks, or gift cards?
Yes
Payment Method

Form SSA-639 (01-2017)
Destroy Prior Editions

No

If Yes, give:

Beginning Date

Ending Date

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Amount

Frequency

Reason

5. Does the payee charge you for any services?
Service

Beginning Date

Yes

No

Ending Date

If Yes, give:

Amount Charged

6. Have you ever asked the payee if you had any money saved and how much?

Frequency

Yes

No

Yes

No

Yes

No

If Yes, what did the payee answer?

7. Do you know how to get in touch with the payee at all times?
If No, explain:

8. Have you ever had difficulty trying to get in touch with the payee?
If Yes, explain:

9. Are you having any problems with the payee?

Yes

No

If Yes, explain:

NOTE TO INTERVIEWER- Were any large or unusual expenses/purchases detected when you examined the
representative payee's records? If so, record and confirm here:

REMARKS:

Form SSA-639 (01-2017)

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REMARKS CONTINUED:

Interviewer's Name and Telephone Number

Form SSA-639 (01-2017)

Date of Interview

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Privacy Act Statement
Sections 205(j) and 1631(a) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to assist us in making a decision on the
performance of your 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 an accurate
decision on the performance of your representative payee and payment of your benefits may
be affected.
We rarely use the information you supply for any purpose other than the reason stated above.
However, we may use it for the administration and integrity of Social Security programs. 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 Census).
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 our Systems of Records Notice
entitled, Master Representative Payee File Systems (60-0222). This notice, additional information
regarding this form, and information regarding our systems and programs, are available on-line at
www.socialsecurity.gov or at any 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.

Form SSA-639 (01-2017)

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