Form SSA-6230 Representative Payee Report (Child)

6230

Representative Payee Report

See Revised PRA
Statement attached

Social Security Administration, P.O. Box 6230, Wilkes-Barre, PA 18767-9956
PAYEE'S NAME AND ADDRESS

REPORT PERIOD

SOCIAL SECURITY NUMBER

FROM:
ID

FORM APPROVED
OMB NO. 0960-0068

TO:
BIC

PC

DOC

CF

TAA

FP

BIC1

CF

BSSN

BIC3

CF

BSSN

BIC2

CF

BSSN

BIC4

CF

BSSN

If change of address, check box and
enter new address on back of report.

This report is about the benefits you received between
and
for the child(ren) named below.
Please read the enclosed instructions before completing this form to help you answer each question.

1.

Were you (the payee) convicted of a crime considered to be a felony between
and
?
If YES, please explain in REMARKS on the back of this form.

2.
3.

Did all the children named below live with you from
to
?
If NO, please explain and provide the child(ren)'s current address in REMARKS on
the back of this form.
Benefits paid to you between
and
Benefits you reported as saved on last year's report.

=$
=$

Total Accountable Amount

=$

A.

Did you (the payee) decide how the $
was spent or saved for
all the children named below?
If NO, please explain in REMARKS on the back of this form.

YES

NO

YES

NO

DOLLAR AMOUNT
(NO CENTS)

much of the $
did you use for the care and support of the
B. How
child(ren) named below between
and
?
how much, if any, of the $
you saved for each child
C. Show
named below as of
. If none, show zeros.
BIC

4.
Savings/
Checking
Account

CHILD'S
NAME

DOLLAR
AMOUNT

BIC

CHILD'S
NAME

DOLLAR
AMOUNT

If you showed an amount in 3.C. above, place an “X ” in the boxes below to show how you are saving the
child(ren)'s benefits. If you have more than one account, you may mark more than one box in each section.

B. TITLE OF ACCOUNT

A. TYPE OF ACCOUNT
U.S. Savings
Bonds

Certificates
of Deposit

FORM SSA-6230-OCR-SM (02-2012)

Treasury
Bills

Other

Child(ren)'s Name
by Your Name

Your Name for
Child(ren)'s Name

Continued on the Reverse

Other

FOR SSA USE ONLY

6230B

5.

ATT

MARK

SIG

UND1

UND2

OTH

Answer the question only if you answered “OTHER” in 4.A. or 4.B. on the front page.
If you answered “OTHER” in 4.A. or B., show the type of account or investment and the
title of the account in which you saved each child's benefits.
CHILD'S NAME

TYPE OF ACCOUNT
OR INVESTMENT

TITLE OF ACCOUNT

REMARKS

NEW ADDRESS

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.
DATE
PAYEE’S SIGNATURE
(If signed by mark (“X”), two witnesses must sign below)

7.

DAYTIME TELEPHONE NUMBER(S)

6.

(Include area code)

8.

Area Code

WITNESS SIGNATURES ARE REQUIRED ONLY IF THE PAYEE’S SIGNATURE ABOVE
HAS BEEN SIGNED BY MARK (“X”).

SIGNATURE OF WITNESS

DATE

SIGNATURE OF WITNESS

DATE

FORM SSA-6230-OCR-SM (02-2012)

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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
15 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments regarding this burden estimate or any other aspect of this collection,
including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.