Form SSA-637 Expanded Monitoring Site Review Questionnaire for Volume

Form SSA-637 (12-2016)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0633

Expanded Monitoring Program
Site Review Questionnaire for Volume and Fee for Service Payees
Pre-visit Background Information for SSA
Use (Complete Prior to Visit)
Check if random review
Organization/Agency/Payee/Name:

Part 1 - Pre-visit Information to Ask Payee
1. Date and time site visit scheduled for (Send confirmation letter.):

2. Address(es) to be visited:

3. Name, title, and phone number of primary contact:

4. Name, title, and phone number of alternate contact:

5. What is the name of the person responsible for each of the following representative payee workloads?
(Include the individual’s title and phone number if not the same person named in question 3 or 4.)
• Receiving and posting benefits to ledgers:

• Administering dedicated accounts:

• Completing annual accounting forms:

• Reporting changes to SSA:

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• Paying beneficiaries’ bills

• Completing SSA forms:

• Determining beneficiary needs:

• Reconciling bank statements:

• Monitoring resource limits:

• Internal audits of beneficiary accounts:

6. Will the responsible staff be available during site visit?

Yes

No

Yes

No

If “No,” explain:

7. Can you send in a list of beneficiaries served including their SSNs, their current
residence addresses, daytime phone numbers, and conserved fund balances;
and a copy of any internal written guidelines for managing beneficiary funds; and
a copy of a sample financial ledger including a key for reading any codes on
the ledger?
If “No,” explain:

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Part 2 - Information from SSA Records
8. Are the payee’s mailing and location addresses and phone number on the
Representative Payee System (RPS) correct?

Yes

No

Yes

No

Yes

No

Yes

No

If “No,” explain and direct the servicing FO to correct RPS:

9. Is the payee listed more than once on the ZIPL screen(s) on RPS?
If “Yes,” explain the error and direct the servicing FO to correct the problem:

10. Is the payee an organization?
If “Yes,”
(a) Enter TOP from RPS (OIRL screen):
(b) Does TOP code match the actual type of payee?
If “No,” explain the error and direct the servicing FO to correct RPS:

11. Enter the total number of Social Security/Supplemental Security Income (SSI) beneficiaries the payee
serves from the OILM screen in RPS:

12. See question 7. Is the conserved fund balance of any SSI beneficiary
more than $2,000 ($3,000 for a couple)?

Yes
No
Balances Not Submitted

If “Yes,” list the beneficiaries below and in question 14 to include in the beneficiary sample. You must
determine if an excess resource issue exists for these beneficiaries during the site review
(See question 87).

Form SSA-637 (12-2016)

13. Does the payee have any overdue annual accounting reports? (Ask the
servicing FO to check the Title II and Title XVI nonresponder lists for overdue
annual accounting forms.)

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Yes

No

If “Yes,” list the names and SSNs of the beneficiaries below and list some of them in question 14 to include
in the beneficiary sample. Resolve the annual accounting report problem with the payee during the site
review (See question 56).

14. List the names and SSNs of beneficiaries selected for the review sample:

15. Does the payee’s list of beneficiaries served and their residence addresses agree
with SSA records? (Compare the list requested in question 7 to the list of
Yes
beneficiaries currently served on RPS. To check residence addresses, begin by
checking the residence addresses on RPS and the SSR for beneficiaries in the sample.)
If “No,” resolve the discrepancy and remedy any reporting problem during the site review.
(See question 57).

16. Is the payee fee for service (FFS)?

No

Yes

No

(a) Print a copy of the RFEE screen from RPS and have it available at the site review.
(b) Does the payee continue to serve at least 5 beneficiaries?
Yes
(See answer to question 11.)
(c) When was the most recent annual certification (see RFEE screen)?

No

If “Yes”:

17. Do SSA records (MBR/SSR) show that the payee uses direct deposit?

Yes

No

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18. Does RPS (RPPR screen) have a collective account precedent?

Yes

No

19. Were any problems noted during the last review? (If the prior report is not
available from the servicing FO or RO, check RPS or the Philadelphia
Representative Payee Monitoring website for information about the results.)

Yes

No

Yes

No

If “Yes,” list the problems:

20. Since the last review (or since appointment as payee, if no prior review) has
the servicing FO received any complaints or have concerns about this
payee’s performance?
If “Yes,” list the complaints and/or concerns:

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Expanded Monitoring Program
Site Review Questionnaire for Volume and Fee for Service Payees
Site Review Interview Guide
(Complete During Visit)
Date of Review:
Servicing Field Office:
Lead Reviewer’s Name:
Lead Reviewer’s Phone Number:

Part 3 - Meeting Information
Information from SSA reviewer:
21. List SSA Meeting Participants:

Information from payee:
22. List Payee Meeting Participants (Include title and phone number, if not listed in question 5):

Part 4 - External Audits
Information from payee:
23. Have you been independently audited within the last 2 years?
24. Can you give us a copy of the most recent audit report and any response you
may have made?
If “No,” explain:

Yes
No
No (if no, go to Part 5)
Yes

No

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Information from SSA reviewer:
25. Do the audit results have a bearing on this site review?

Yes

No

If “Yes,” explain (e.g., payee not solvent, poor recordkeeper):

Part 5 - Licensing
(Complete this Part only if the payee is nongovernmental FFS, otherwise go to Part 7.)
Information from payee:
26. Is your organization licensed?

Yes

No

Yes

No

Yes

No

If “Yes,” provide SSA with a copy of the license.
If “No,” explain (e.g., licensing not available in jurisdiction, license expired):

Information from SSA reviewer:
27. Does the payee continue to meet licensing requirements?
If “Yes,” update the RFEE screen on RPS.
If “No,” explain why not and update the RFEE screen on RPS.

Part 6 - Bonding
(Complete this Part only if the payee is nongovernmental FFS.)
Information from payee:
28. Is your organization bonded?
If “Yes,” provide SSA with a copy of the bond.
If “No” explain:

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Information from SSA reviewer:
29. If the payee is bonded, calculate the minimum required bond amount for this payee:
a. Average amount of social security and SSI benefits received in
one month:

$

b. Amount of conserved funds on hand:

$

c. Add a. and b. for minimum required bond amount for this payee:

$

30. If the payee is bonded, is the bond amount sufficient to cover the number of
beneficiaries the payee serves? (Minimum coverage must equal or exceed the
amount in 29.c.)

Yes

No

31. Does the payee continue to meet bonding requirements?

Yes

No

Yes

No

If “Yes,” update the RFEE screen on RPS.

If “No,” explain why not and update the RFEE screen on RPS:

Part 7 - Fee Charging
(Ask all payees these fee charging questions.)
Information from payee:
32. a. Do you charge a fee to beneficiaries directly for payee services or for any
other service you provide (e.g., SSA-approved FFS, fee deducted from
personal needs allowance of institutionalized beneficiaries, fee for
administrative expenses)?
b. If “Yes,” list:
Beginning Date

Frequency
(e.g., monthly, weekly)

Reason for Fee

How Fee Determined or Fee
Amount

33. a. Have you collected fees from beneficiaries for past months from either current
or retroactive benefits?

Yes

No

Form SSA-637 (12-2016)

b. If “Yes,” list:
Beginning and Ending
Dates

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Amount

Frequency
(e.g., monthly, weekly)

Reason for Fee

34. Do you collect a fee or receive a payment for services from any source other
than the beneficiaries (e.g., court or guardianship fees, fees from a State agency
for providing services to the beneficiary)?
If “Yes,” list:
Beginning and Ending
Dates

Amount

Frequency
(e.g., monthly, weekly)

Yes

No

Reason for Fee

35. If you charged any fees, have you waived fees whenever monthly living
expenses exceeded the amount of the monthly benefit?

Yes

No

Situation has not occurred

If “No,” what was the impact on the beneficiary(ies)?:

Information from SSA reviewer:
36. Did the payee break any SSA rules regarding fee charging? (A FFS payee is
permitted to collect the lesser of 10% of monthly benefit or the current allowable
amount less any compensation for payee services from another source.)

Yes

No

If “Yes,” explain:

Part 8 - Determining Beneficiary Needs
Information from payee:
37. How often and under what circumstances do you see/speak to the beneficiaries to keep informed of their
needs? (For children in foster care, how often do social workers visit the children to keep informed of their
needs and welfare?)

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38. Do beneficiaries have ready access to you?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

If “No,” how do you ensure beneficiary needs are met?

39. Do you actively help beneficiaries in other ways (e.g., trying to negotiate the
best deals from landlords, grocers, and banks; shopping for bargains and
sales; learning of needs; seeking medical help; finding suitable housing;
establishing a process for social workers to obtain necessary items/services
for a foster child; notifying adoptive parents that a child may be eligible for benefits)?
Explain answer:

40. If you serve institutionalized beneficiaries, do you set aside at least $30 per
month for their personal needs?
If “No,” explain:

41. If you serve non-institutionalized beneficiaries do you set aside any money
for discretionary spending (exclude charges for care and maintenance)?
Explain answer:

42. If the beneficiaries are children in foster care, do you set aside some of the
children’s own funds or provide funds for children when they attain age 18
to help them transition into adulthood?
Explain answer:

43. Do any beneficiaries in the sample have unmet needs?
If “Yes,” explain:

Part 9 - Use of Benefits
Information from payee:
44. Do any beneficiaries live in a facility(ies) or housing that you, a relative of yours,
or your organization own or operate?
If “Yes,” explain the arrangement:

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45. How do you establish and/or budget for current maintenance costs?

46. Do you save for beneficiaries’ future needs?

Yes

No

Yes

No

If “No,” explain:

47. Do you ever disburse cash, including negotiable instruments such as checks,
debit cards, gift cards and money orders, directly to a beneficiary other than
small sums for discretionary spending or personal needs or disburse cash to
a third party?
If “Yes,” for each beneficiary list:
Name

SSN

Amount

Frequency
(e.g.
weekly)

Method
(e.g. cash,
check)

48. a. Did you receive any past-due (retroactive) benefits which were used to pay
a past debt owed to you?
b. If “Yes,” was SSA approval obtained?

Reason for
Disbursement

Yes
No
No (if no, go to 49)
Yes
No

If “No,” explain:

Information from SSA:
49. a. Is the payee a “conduit” payee (a payee who turns over all or most money to a
beneficiary or someone else to decide how to use) for any beneficiary?

Yes
No
No (if no, go to 50)

b. If “Yes,” explain how the payee is mismanaging disbursements:

c. List:
Beneficiary Name

SSN

Action Required to Resolve

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50. Does the payee receive and disburse benefits in the best interests of
the beneficiaries?

Yes

No

If “No,” explain:

Part 10 - Reporting Events
Information from payee:
51. What process do you use to report changes (e.g., change of address, income, resources, reports
of death to 800# or servicing FO) that affect Social Security or SSI benefits?

52. What process do you use to report when a beneficiary is no longer in your care (e.g., adoption of a child in
foster care) or you have lost contact with a beneficiary and to report changes in a beneficiary’s
competency (appointment of a guardian)/capability?

53. How do you handle conserved funds when a beneficiary is transferred or discharged from your care
(funds must be returned to SSA) or dies (conserved funds of deceased beneficiaries must be turned over
to estate)?

54. What process do you have in place to insure the completion of annual accounting reports, work
and/or medical continuing disability reviews, and SSI redeterminations?

55. Do you negotiate or deposit the Social Security or SSI checks of any
beneficiaries for whom you are not the representative payee in an
operating account?

Yes

No

Yes

No

If “Yes,” list the names and SSNs of these beneficiaries:

Information from SSA Reviewer:
56. Does the payee submit accurate and timely annual accounting reports
(See the answers to questions 13 and 54.)?

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If “No,” explain the plan for remedying this problem and the plan for the payee to submit overdue reports:

57. Does the payee submit other reports timely?

Yes

No

If “No,” explain and include plans for correcting reporting problems: (Exclude annual accounting reports
because they are covered in question 56. Include your resolutions to any issues raised by answers to
questions 15, 19, 20, and 55. Provide the names and SSNs of beneficiaries named in question 55 to the
servicing FO if development of assignment of benefit and capability issues is necessary.)

Part 11 - Payee’s Banking Procedures (See answer to question 17.)
Information from payee:
58. Do you use direct deposit for all beneficiaries?

Yes

No

Yes

No

If “No,” explain why not, and how paper checks are safeguarded until negotiated:

59. Do you keep beneficiary funds in a bank account(s)?

If “Yes,” describe the type of account(s) used and how you use the accounts to help manage the
beneficiaries’ funds (e.g., benefits received in a collective checking account via direct deposit, checks for
living expenses written from collective account, conserved funds held in individual savings accounts) and
to pay beneficiary bills:

If “No,” explain how you manage beneficiary funds and pay beneficiary bills:

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Part 12 - Collective Accounts
(Complete this Part if the payee reported a collective account in question 59. Otherwise go to
Part 13, if the payee reported a checking and/or savings account in question 59; or go to
Part 14, if the payee reported no accounts in question 59.)
Information from payee:
60. Provide the following information about the collective account:

Bank Name
& Address:

Account #:
Title of Account (format):
Type of Account:

Savings

Checking

61. Does the bank charge any fees?

Yes

No

Yes

No

Yes

No

Yes

No

If “Yes,” how much are the fees and what are they for?

62. Are the fees charged to the beneficiaries?
If “Yes,” explain the fee-charging method:

Information from SSA reviewer:
63. Is the collective account correctly titled?
If “No,” explain:

64. Is the collective account separate from payee’s operating account?
65. Is interest prorated and credited to beneficiaries on the basis of their share
of account funds?

Yes
No
Account not interest-bearing

If “No,” explain:

66. Are records showing each beneficiary’s share of account clear and up to date?

Yes

No

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67. Does the payee correctly document credits and debits of each beneficiary?
68. Are there any problems with the account (other than any titling problem
addressed in questions 63)?
If “Yes,” explain:

Yes

No

Yes

No

69. Does the collective account meet SSA requirements for re-approval?

Yes

No

If “Yes,” update the RPPR screen.
If “No,” update the RPPR screen and explain:

Part 13 - Checking and Savings Accounts
(If the payee reported a checking and/or savings account in question 59, complete this Part.
If the payee reported more than one checking and/or savings account in question 59,
record information about the first checking or savings account in questions 70 through 73
and use the Remarks/Observations section to record information required in questions
70 through 73 for the additional account(s)).
Information from payee:
70. Provide the following information about the account(s):

Bank Name
& Address:

Title of Account (format):
Type of Account:

Savings

Checking

List Beneficiary Names (in the sample) and Account #’s (Complete this item when account is not the direct
deposit account on MBR/SSR):

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71. Does the account earn interest and are beneficiaries credited with the interest?

Yes

No

If “Yes,” explain how and when interest is credited and how reflected in the payee’s records:

If “No,” why not?

72. Does the bank charge any fees?

Yes

No

If “Yes,” what are the fees for, how much are they, and how are they charged to beneficiaries?

Information from SSA reviewer:
73. Are accounts (other than any collective account addressed in question 63)
holding beneficiary funds properly titled?

Yes

No

Yes

No

If “No,” explain and describe the scope of the problem:

74. Are there any problems with the account(s) (other than any titling problem
addressed in question 73 and other than any collective account problems
addressed in questions 63 and 68)?
If “Yes,” explain:

Part 14 - Dedicated Accounts
Information from payee:
75. Were you required to establish a “dedicated” account for a minor child/individual
receiving SSI benefits?

Yes
No
No (If no, go to part 15)

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76. Do you still maintain funds in a dedicated account?
Yes
No
Note to Review Team: If payee maintains a dedicated account and the SSN was not included in the
review sample, ask the payee to provide a list of SSI beneficiaries with dedicated accounts and
review at least 1 case.
If “No,” explain how funds were used and go to question 78:

77. Did you make expenditures from this account during the period of review?

Yes

No

Yes

No

Yes

No

If “Yes,” explain what expenditures were for:

Information from SSA reviewer:
78. Were dedicated accounts managed properly (any expenditures were for medical
treatment, education, job skills training, other expenses related to the
beneficiary’s impairment).
If “No,” explain:

Part 15 - Other Financial Instruments
Information from Payee:
79. Do you hold any conserved funds of beneficiaries in the sample in another
account (e.g.,burial account, money market account) not previously mentioned
or by another method (e.g.,mutual funds, property)?
If “Yes,” describe and provide evidence of the financial instrument or property:

Part 16 - Recordkeeping
Information from payee:
80. Describe your recordkeeping system (e.g., paper ledgers, automated ledgers, patient accounts
maintained on site, check ledgers) . Include in your description:

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• Any internal controls in place (e.g., periodic record reconciliations, independent audits, internal audits,
countersignature requirements, separation of employee duties, restricting access to beneficiary
accounts, safe or locked cabinets for checks stock, etc.) for monitoring and safeguarding individual
beneficiary funds;
• Your process for paying beneficiary bills and the supporting documentation you maintain; and
• Your procedures for providing beneficiaries with discretionary spending money or a personal needs
allowance and overseeing these disbursements.

81. Have you filed a claim with an insurer due to employee dishonesty, or fired, or
asked any employees to resign due to bookkeeping irregularities within the
past 24 months?

Yes

No

Yes

No

If “Yes,” explain:

Information from SSA reviewer:
82. Are the financial records (ledgers, receipts/invoices, bank statements,
cancelled checks) retrievable and orderly?
If “No,” explain:

Form SSA-637 (12-2016)

83. Do ledgers correctly and clearly identify both receipts of benefits and
expenditures; and do checking account registers, cancelled checks, and
receipts/invoices correctly and clearly identify expenditures?

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Yes

No

Yes

No

Yes

No

Yes

No

If “No,” explain:

84. Are records accurate (all funds accounted for, ledger balance for individual
beneficiaries equals the balance shown on the corresponding bank statements)
and up-to-date (benefit payments and expenditures posted to ledgers and
checking account registers timely) ?
If “No,” explain:

85. Are you able to follow the electronic or paper trail that supports the receipt and
disbursement of beneficiary funds?
If “No,” explain:

86. Did the payee make any expensive or unusual purchases for beneficiaries
in the sample?
If “Yes,” list (so you can complete the Note to Interviewers on the SSA-639.):
Purchase
Beneficiary Name
Item/Service
Date

87. For SSI beneficiaries in the sample, does any SSI beneficiary’s ledger reflect a
balance/combined balance over $2,000 ($3,000 for a couple) as of the first
moment of any month during the entire review period? (See the answer to
question 12 and review ledger balances for the period of review. Substitute bank
records if payee does not keep a ledger or ledgers are inaccurate.)

Payee’s
Documentation

Yes

No

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If “Yes,” list:
Name

SSN

Resource Description

Dates Ineligible

88. Did the payee conserve unspent funds appropriately?

Beginning and
Ending Balance

Yes

No

If “No,” explain: (Recommend placing conserved funds regardless of amount in interest-bearing accounts.):

Part 17 - Other
Information from payee:
89. Do you need any help to carry out payee duties from SSA or do you need
SSA’s help to resolve any problems?

Yes

No

Yes

No

If “Yes,” explain:

Information from SSA reviewer:
90. Does SSA need to provide training to the payee in any area?
If “Yes,” explain what is needed and how it will be accomplished:

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91. If you answered question 19 or question 20 “Yes,” has the payee corrected
the problems noted?

Yes

No

If “No,” explain:

Part 18 - Beneficiary Interview Sample
Information from SSA reviewer:
92. Tell the payee the names of the beneficiaries in the sample that you plan to interview (include any
beneficiaries listed in question 86) and list their names below:

Information from payee:
93. Do any of these beneficiaries have difficulty responding to questions?
Yes
If “Yes,” what are their names and what is the name of each one’s custodian/caregiver, job title
(e.g., social worker, nurse, home health aid) or concerned relative, and phone number:
Beneficiary:
Contact Name:
Title/Relation:
Phone:
Beneficiary:
Contact Name:
Title/Relation:
Phone:
Beneficiary:
Contact Name:
Title/Relation:
Phone:

No

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Part 19 - Remarks/Observations (for SSA use)

Part 20 - Recommendations and Action Items (for SSA use)
Payee:

SSA:

Date interview guide and closeout letter to FO/RO:

Form SSA-637 (12-2016)

See Revised Privacy Act &
PRA Statements attached

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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 the monitoring your performance
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 an accurate decision on your
performance as a representative payee.
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 Veteran's 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).
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 2 hours 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.