Form SSA-623-F6 Representative Payee Report

What Is Form SSA-623-F6?

Form SSA-623-F6, Representative Payee Report is a form used to report how you as a representative payee use the benefits you receive on behalf of another person who is a Social Security or Supplemental Security Income (SSI) beneficiary.

The form - also known as SSA Form 623-F6 - was issued by the Social Security Administration (SSA). The latest version of the document was released in August 2013 with previous editions obsolete. No printable Form SSA-623 copies can be found online. Download а copy of SSA-623-F6 down below.

A representative payee is an individual or organization that handles the social security or SSI benefits for a person who is unable to manage them. A representative payee is responsible for ensuring the benefits are spent to pay for the medical expenses and everyday living of the beneficiary. The funds must be spent only on expenses approved by the SSA. The representative payee must keep all records and report on using the beneficiary's funds.

The SSA reviews the usage of benefits by the representative payees regularly. That is why they send the representative payee a report Form SSA-623. You must provide all the information required for the period indicated in the document. Use the records you keep to answer the questions. A similar form is Form SSA-6230-OCR-SM, Representative Payee Report. It is a form with the same name, but it goes under a different number.

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Social Security Administration
Representative Payee Report
Why You Received
We must regularly review how representative payees used the benefits they
received on behalf of the Social Security and/or Supplemental Security
This Form
Income (SSI) beneficiaries. We do this to ensure the benefits are used
properly. When you were appointed representative payee, you were informed
of the duties and responsibilities of a representative payee, including keeping
records and reporting on the use of benefits.
What You Need
You must report to SSA on your use of benefits if you received any Social
Security and/or SSI payments during the 12 month period shown on the
To Do
enclosed form. You must do this if you wish to continue receiving benefits on
behalf of another person. You should use the records you have saved to
answer the questions on the enclosed form.
You may submit this form online via
www.ssa.gov/payee
. Please follow the
instructions for Internet Payee Accounting Report. If you complete the form
online, you will be able to print a receipt and a copy of your report. If you
report online, you should have all your records and the enclosed form handy
to help you answer the questions. You should not send in a paper form if you
complete the online version.
Any records you have saved such as bank statements, cancelled checks,
receipts for rent, etc., should be kept for two years from the time you file your
report with SSA. You should not send in any of these records with your
report form. If we have any questions or require proof, we will contact you.
General Instructions
Please read these instructions before you complete the enclosed report form
or submit your report online. You should either complete and return the
If You Complete and
report form, or submit the online report, within 30 days.
Return The
To help us process your report, please follow these instructions:
Enclosed Form
1. Use black ink.
2. Keep your numbers and “X’s” inside the boxes.
3. Do not use dollar signs.
4. Show money amounts in dollars only. Do not show cents.
For example, show $1,540.30 like this:
DOLLAR AMOUNT
1
5 4 0
,
5. Use the REMARKS section on the back of the form to provide additional
information as requested.
6. Review the payee mailing address and correct if necessary. If you change
the payee mailing address to a P.O. Box, show the payee’s actual physical
address in REMARKS.
7. Be sure you, the representative payee, sign the form.
Form SSA-623-F6 (08-2013) ef (08-2013)
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Social Security Administration
Representative Payee Report
Why You Received
We must regularly review how representative payees used the benefits they
received on behalf of the Social Security and/or Supplemental Security
This Form
Income (SSI) beneficiaries. We do this to ensure the benefits are used
properly. When you were appointed representative payee, you were informed
of the duties and responsibilities of a representative payee, including keeping
records and reporting on the use of benefits.
What You Need
You must report to SSA on your use of benefits if you received any Social
Security and/or SSI payments during the 12 month period shown on the
To Do
enclosed form. You must do this if you wish to continue receiving benefits on
behalf of another person. You should use the records you have saved to
answer the questions on the enclosed form.
You may submit this form online via
www.ssa.gov/payee
. Please follow the
instructions for Internet Payee Accounting Report. If you complete the form
online, you will be able to print a receipt and a copy of your report. If you
report online, you should have all your records and the enclosed form handy
to help you answer the questions. You should not send in a paper form if you
complete the online version.
Any records you have saved such as bank statements, cancelled checks,
receipts for rent, etc., should be kept for two years from the time you file your
report with SSA. You should not send in any of these records with your
report form. If we have any questions or require proof, we will contact you.
General Instructions
Please read these instructions before you complete the enclosed report form
or submit your report online. You should either complete and return the
If You Complete and
report form, or submit the online report, within 30 days.
Return The
To help us process your report, please follow these instructions:
Enclosed Form
1. Use black ink.
2. Keep your numbers and “X’s” inside the boxes.
3. Do not use dollar signs.
4. Show money amounts in dollars only. Do not show cents.
For example, show $1,540.30 like this:
DOLLAR AMOUNT
1
5 4 0
,
5. Use the REMARKS section on the back of the form to provide additional
information as requested.
6. Review the payee mailing address and correct if necessary. If you change
the payee mailing address to a P.O. Box, show the payee’s actual physical
address in REMARKS.
7. Be sure you, the representative payee, sign the form.
Form SSA-623-F6 (08-2013) ef (08-2013)
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Some Definitions
Benefits – The Social Security and/or SSI money that you receive.
Payee – You. The person (or organization) who receives Social Security
To Help You
and/or SSI benefits for someone else.
Beneficiary – The person for whom you receive Social Security and/or
SSI benefits.
Legal Guardian – The person or organization appointed by a State court to
manage the affairs of a beneficiary.
Report Period – The 12-month period shown on the report for which you
must account for the benefits you received.
Total Accountable Amount – The amount of benefits paid to you during the
report period plus any amount you reported as saved on last year’s report.
HOW TO FILL OUT THE FORM
QUESTION 1 -
Place an “X” in the “YES” box if during the report period, you (the payee)
were convicted of a crime considered to be a felony and explain the type of
Payee Felony
crime under REMARKS. Otherwise, place an “X” in the “NO” box.
Convictions
QUESTION 2 -
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
Beneficiary
period. Place an “X” in the “NO” box if different people or different
Custody Changes
institutions took care of the beneficiary during any part of the report period.
Explain the change and provide the beneficiary’s current address
under REMARKS.
QUESTION 3 -
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.
Accounting
For Benefits
A.
Who Decided
Place an “X” in the “YES” box if you (the payee) decided how the benefits
were to be spent or saved. Place an “X” in the “NO” box if the beneficiary or
How Benefits
someone else decided how to use the money, and explain under REMARKS.
Were Used?
B.
Food And
Show the total amount of benefits spent for food and housing for the
beneficiary during the report period. If the beneficiary lives in an institution
Housing
or nursing home and you pay monthly charges, multiply the monthly charge
by 12 and show this total amount.
C.
Personal
Show the total amount of benefits spent on clothing, medical/dental care,
education, and recreational items like toys, movies, cameras, radios, candy,
Items
stationary, grooming aids, etc. during the report period. Note: If the
beneficiary lives in an institution or other care facility, you should spend at
least $360 a year for the beneficiary’s personal needs. If you spent less than
$360, explain under REMARKS.
D.
Unused
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
Benefits
not save any of the benefits.
Note
For Social Security beneficiaries who are residing in an institution, use
REMARKS to provide the amount of benefits, if any, the state Medicaid
agency has determined are for the use of the community spouse and other
dependents, if applicable.
2
Form SSA-623-F6 (08-2013) ef (08-2013)
QUESTION 4 - Savings
Answer this question if you showed an amount in 3.D.
Information
A.
Type Of
Place an “X” in the box which shows how you are saving the benefits. Place
an “X” in the “Other” box if your method of saving the benefits is not listed.
Account
B.
Account
Place an “X” in the box which most accurately describes the wording of the
account title you have on the beneficiary’s savings. Place an “X” in the
Title
“Other” box if the account title is different or if you have not placed the
savings in any type of account. Note: A savings or checking account title
should always show that the money belongs to the beneficiary, but the
beneficiary should not have direct access to the funds.
QUESTION 5 - Other
Answer this question only if you checked “OTHER” in 4.A. or 4.B.
Savings/ Account Titles
Type Of
A.
Indicate whether the saved benefits are in cash, Treasury Bills, or some other
Account
investment such as mutual funds. For mutual funds, be sure to show the name
of the fund in your response (e.g., “XYZ Growth” mutual fund).
Title Of
B.
Show the title of the account if the savings are in an account or other
investment. Show “none” if the savings are not in an account or investment.
Account
Payee’s
6.
Sign your name in this block. If you sign by mark (“X”), please have two
Signature
witnesses sign their names and show the date. If the payee is an institution or
agency, the form must be signed by an authorized person.
Form SSA-623-F6 (08-2013) ef (08-2013)
3
We may also disclose information to another person or to
Your Responsibilities As
another agency in accordance with approved routine uses,
Representative Payee
which include, but are not limited to, the following:
We appreciate your services as representative payee. As
1. To comply with Federal laws requiring the release
payee, you must use the Social Security and/or SSI
of information from Social Security records (e.g.
benefits you receive for the care and well being of the
to the Government Accountability Office and
beneficiary. You need to know the beneficiary’s needs so
Department of Veterans Affairs);
that you can use the money properly.
2. To facilitate statistical research, audit , or
investigative activities necessary to assure the
In addition to reporting on the use of benefits, you must
integrity and improvement of Social
report any changes which may affect the beneficiary’s
Security programs;
eligibility for benefits, or the payment amount. You
3. To respond to a request on your behalf from a
should report the changes as soon as possible by calling
Congressional office or the Office of the
SSA at 1-800-772-1213, or by calling or writing your
President; and
local SSA office. For example, you must tell us if
4. To other Federal agencies and our contractors,
the beneficiary:
including external data sources, to assist us in
efficiently administering our programs.
dies,
We may also use the information you give us in computer
moves (especially if he/she enters or leaves a
matching programs. Matching programs compare our
hospital or other institution),
records with records kept by other Federal, State, or local
marries,
government agencies. We use the information from these
starts or stops working,
programs to establish or verify a person's eligibility for
is imprisoned,
federally funded or administered benefit programs and for
is adopted,
repayment of incorrect payments or delinquent debts
no longer needs a payee, or
under these programs.
you are no longer responsible for the beneficiary.
A complete list of routine uses for this information is
If you are payee for a child receiving SSI benefits, we
available in our Privacy Act System of Records Notice
may ask you for proof that the child is receiving medical
(SORN) entitled, Master Representative Payee File
treatment for his/her disabling condition. We may ask for
(60-0222). The complete SORN, additional information
this information at the time we review the child’s case. If
about this form, routine uses of information, and our
we do ask for this information, you must give it to us.
programs and systems are available online at
www.socialsecurity.gov
or your local Social
If you are no longer payee for the beneficiary, you must
Security office.
return any Social Security funds you have saved to SSA.
Paperwork Reduction Act Statement - This information
See Revised Privacy Act and Paperwork
collection meets the requirements of 44 U.S.C. §3507, as
Reduction Act Statements attached.
amended by section 2 of the Paperwork Reduction Act of
1995 . You do not need to answer these questions unless
Privacy Act Statement
we display a valid Office of Management and Budget
control number. We estimate that it will take about 15
Collection and Use of Personal Information
minutes to read the instructions, gather the facts, and
Sections 205(j) and 1631(a) of the Social Security Act, as
answer the questions. You may send comments on our time
amended, authorize us to collect this information to enable
estimate above to: SSA, 6401 Security Blvd, Baltimore,
us to account for the beneficiary's payments and to ensure
MD 21235 . Send only comments relating to our time
that you use the payments for the beneficiary's needs.
estimate to this address, not the completed form.
Your responses are voluntary. However, without the
information, we may not be able to continue sending the
If You Have Any Questions
beneficiary's payments to you.
We rarely use the information you give us for any purpose
If you have any questions, please call us at
other than for accounting purposes. However, we may use
1-800-772-1213. We can answer most questions over the
it for the administration and integrity of Social
phone. If you prefer to visit one of our offices, please use
Security programs.
the 800 number and we will give you the address and
telephone number of the office nearest you. Please take
this report with you if you visit an office. You may also
visit our website at www.socialsecurity.gov.
Form SSA-623-F6 (08-2013) ef (08-2013)
4
Representative Payee Report
FORM APPROVED
OMB NO. 0960-0068
SOCIAL SECURITY NUMBER
REPORT PERIOD
PAYEE'S NAME AND ADDRESS
FROM:
TO:
BENEFICIARY
FP
D
ID
BIC
TP
GS
PC
CC
DOC
CF
TAA
PF
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
beneficiary,
. Please read the enclosed instructions before
completing this form to help you answer each question.
1.
NO
YES
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.
Did the beneficiary continue to live alone, or with the same person, or in
the same institution from
to
? If NO, please
explain and provide the beneficiary's current address in REMARKS on the
back of this form.
3.
Benefits paid to you between
and
= $
= $
Benefits you reported as saved on last year's report
Total Accountable Amount
= $
YES
NO
A.
Did you (the payee) decide how the
was
spent or saved?
u
If NO, please explain in REMARKS on the back of this form.
DOLLAR AMOUNT
B.
How much of the
did you spend for the beneficiary's
(NO CENTS)
u
food and housing between
and
,
?
C.
How much of the
did you spend on other things
for the beneficiary such as clothing, education, medical and
,
dental expenses, recreation, or personal items
u
between
and
?
D.
How much, if any, of the
did you save for the
,
beneficiary as of
? If none, show zeroes.
u
4.
If you showed an amount in 3.D. above, place an “X” in the boxes below to show how you are saving
the benefits. If you have more than one account, you may mark more than one box in each section.
A. TYPE OF ACCOUNT
B. TITLE OF ACCOUNT
Treasury
Beneficiary's Name
Your Name for
Savings / Checking
U.S. Savings
Certificates
Collective Savings/
Other
Other
Bills
by Your Name
Beneficiary's Name
Account
Bonds
of Deposit
Checking Account
Form SSA-623-F6 (08-2013) ef (08-2013)
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How to Fill out Form SSA-623?

Complete and submit the form within 30 days after receiving it. Use black ink when filling out the document. Do not use the dollar sign and show all required amounts in dollars only (do not enter cents).

The instructions are as follows:

  1. Indicate if you were convicted of a felony during the reporting period. If yes, provide the type of crime in "Remarks" box;
  2. Answer "Yes" to question 2 if the beneficiary continued to live with the same person, in the same institution or alone during the reporting period. If during any part of this period other people or institutions took care of the beneficiary, answer "No" and comment in the "Remarks" box;
  3. Provide the details on the accounting for beneficiary for the reporting period. Include total accountable amount, food, housing, and personal items expenses. Enter the total amount of unused benefits, if any. If you did not save any benefits, enter "0". Indicate who decided how to use benefits. If it were not you, provide the explanations in the "Remark" box;
  4. Fill out question 4 only if you showed an amount in question 3D. Indicate the account type and title;
  5. If you checked "Other" in question 4A or B, provide the details in question 5;
  6. Sign your name. If you sign with "X", you must have two witnesses to sign too. If the payee is an organization, the document must be signed by an authorized representative only;
  7. Enter the date;
  8. Indicate your daytime phone number.

You will receive the detailed instruction and all completion requirements with the form you must complete. If you need any help with the document, contact the local Social Security office.

Where to Mail Form SSA-623-F6?

The SSA sends an envelope with an enclosed Form SSA-623-F6. Place your completed form in the envelope and return it to the SSA office indicated on the form. Do not include any records like checks or receipts. However, keep them for two years from the date you filed the form. If the SSA requires a proof, they will notify you.

You can also submit the form online. The link will be provided with the form. In this case, you can print a copy of your report after completion. You do not need to submit a paper version of Form SSA-623, if you filled out an electronic one.

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