Form SSA-11-BK Request to Be Selected as Payee

What Is Form SSA-11-BK?

Form SSA-11-BK, Request to be Selected as Payee is a form used to apply to be a representative payee. A representative payee is a person who manages the benefits of a disabled person when they are unable to do so themselves or have difficulties in managing their money due to their condition. Usually, the Social Security Administration (SSA) assigns a person to be a representative payee. In most cases, this is a close relative. Sometimes, the SSA can assign an organization to manage the benefits.

A representative payee receives the beneficiary's funds and manages them. The SSA requires payees to keep a record of expenses and be ready to provide it upon request. A payee cannot make any decisions regarding a beneficiary's placement and treatment. They are not allowed to transfer funds to their own bank account and use them for personal needs. If a payee misuses the funds, the SSA will assign another person or organization.

If the payee's services are no longer required by the beneficiary, they should file a request for direct payment using this form. The SSA will require their physician to fill out the form SSA-787 to obtain information about the beneficiary's ability to manage funds.

The form SSA-11-BK, also known as SSA Form 11-BK, is only the first step in becoming a representative payee. The SSA also requires a face-to-face interview, phone interview or video service delivery interview. The application should be filed via the electronic Representative Payee System (eRPS). The paper version of the application is used only if the eRPS is unavailable or it is impossible to use it. A printable SSA-11-BK Form was released in August 2009 and is available below for reference.

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Form Approved
SOCIAL SECURITY ADMINISTRATION
TOE 250
OMB No. 0960-0014
FOR SSA USE ONLY
FOR SSA USE ONLY
Name or
Date of
Program
Type
Gdn.
Cus.
Inst.
Nam.
Bene. Sym.
Birth
REQUEST TO
BE SELECTED
AS PAYEE
DISTRICT OFFICE CODE
STATE AND COUNTY CODE:
PRINT IN INK:
The name of the NUMBER HOLDER
SOCIAL SECURITY NUMBER
The name of the PERSON(S) (if different from above) for whom you are filing (the
SOCIAL SECURITY NUMBER(S)
"claimant(s)")
Answer item 1 ONLY if you are the claimant and want your benefits paid directly to you.
1.
I request that I be paid directly.
CHECK HERE
and answer only items 3, 5, 6, and 8 before signing the form on page 4.
I REQUEST THAT THE SOCIAL SECURITY, SUPPLEMENTAL SECURITY INCOME, OR SPECIAL VETERANS BENEFITS
FOR THE CLAIMANT(S) NAMED ABOVE BE PAID TO ME AS REPRESENTATIVE PAYEE.
2.
Explain why you think the claimant is not able to handle his/her own benefits.
(In your answer, describe how he/she manages any money he/she receives now.)
Claimant is a minor child.
3.
Explain why you would be the best representative payee. (Use Remarks if you need more space.)
4.
If you are appointed payee, how will you know about the claimant's needs?
Live with me or in the institution I represent.
Daily visits.
Visits at least once a week.
By other means. Explain:
5.
Does the claimant have a court-appointed legal guardian/conservator?
YES
NO
IF YES, enter the legal guardian/conservator's:
NAME
ADDRESS
PHONE NUMBER
TITLE
DATE OF APPOINTMENT
Explain the circumstances of the appointment. (Use remarks if you need more space.)
Form SSA-11-BK (08-2009)
EF (08-2009)
Page 1
Destroy Prior Editions
Form Approved
SOCIAL SECURITY ADMINISTRATION
TOE 250
OMB No. 0960-0014
FOR SSA USE ONLY
FOR SSA USE ONLY
Name or
Date of
Program
Type
Gdn.
Cus.
Inst.
Nam.
Bene. Sym.
Birth
REQUEST TO
BE SELECTED
AS PAYEE
DISTRICT OFFICE CODE
STATE AND COUNTY CODE:
PRINT IN INK:
The name of the NUMBER HOLDER
SOCIAL SECURITY NUMBER
The name of the PERSON(S) (if different from above) for whom you are filing (the
SOCIAL SECURITY NUMBER(S)
"claimant(s)")
Answer item 1 ONLY if you are the claimant and want your benefits paid directly to you.
1.
I request that I be paid directly.
CHECK HERE
and answer only items 3, 5, 6, and 8 before signing the form on page 4.
I REQUEST THAT THE SOCIAL SECURITY, SUPPLEMENTAL SECURITY INCOME, OR SPECIAL VETERANS BENEFITS
FOR THE CLAIMANT(S) NAMED ABOVE BE PAID TO ME AS REPRESENTATIVE PAYEE.
2.
Explain why you think the claimant is not able to handle his/her own benefits.
(In your answer, describe how he/she manages any money he/she receives now.)
Claimant is a minor child.
3.
Explain why you would be the best representative payee. (Use Remarks if you need more space.)
4.
If you are appointed payee, how will you know about the claimant's needs?
Live with me or in the institution I represent.
Daily visits.
Visits at least once a week.
By other means. Explain:
5.
Does the claimant have a court-appointed legal guardian/conservator?
YES
NO
IF YES, enter the legal guardian/conservator's:
NAME
ADDRESS
PHONE NUMBER
TITLE
DATE OF APPOINTMENT
Explain the circumstances of the appointment. (Use remarks if you need more space.)
Form SSA-11-BK (08-2009)
EF (08-2009)
Page 1
Destroy Prior Editions
6.
(a) Where does the claimant live?
Alone
In my home (Go to (b).)
In a public institution (Go to (c).)
With a relative (Go to (b).)
In a private institution (Go to (c).)
With someone else (Go to (b).)
In a nursing home (Go to (c).)
In a board and care facility (Go to (b).)
In the institution I represent (Go to (c).)
(b) Enter the names and relationships of any other people who live with the claimant.
NAME
RELATIONSHIP
(c) Enter the claimant's residence and mailing addresses (if different from yours).
Residence:
Mailing:
Telephone Number:
(d) Do you expect the claimant's living arrangements to change in the next year?
YES
NO
If YES, explain what changes are expected and when they will occur. (Use Remarks if you need more
space.)
7.
If you are applying on behalf of minor child(ren) and you are not the parent,
Does the child(ren) have a living natural or adoptive parent?
YES
NO
If YES, enter: (a) Name of parent
(b) Address of parent
(c) Telephone number
(d) Does the parent show interest in the child?
YES
NO
Please explain.
8.
List the names and relationship of any (other) relatives or close friends who have provided support and/or show active interest
with the claimant. Describe the type and amount of support and/or how interest is displayed.
NAME
ADDRESS/PHONE NO.
RELATIONSHIP
DESCRIBE
9.
Check the block that describes your relationship to the claimant.
(a)
Official of bank, agency or institution with responsibility for the person. Enter below which you represent:
Bank
Social Agency
Public Official
Institution:
Federal
State/Local
Private non-profit
Private proprietary institution. Is the institution licensed under State law?
YES
NO
IF (a) ABOVE CHECKED, COMPLETE ONLY QUESTIONS 10 AND 11 AND SIGN THE FORM ON PAGE 4.
(b)
Parent
(c)
Spouse
(d)
Other Relative - Specify
(e)
Legal Representative
(f)
Board and Care Home Operator
(g)
Other Individual - Specify
IF (b), (c), (d), or (e) ABOVE CHECKED, GO ON TO QUESTION 12
Form SSA-11-BK (08-2009)
EF (08-2009)
Page 2
Does the claimant owe you/your organization any money now or will he/she owe you money in the future?
YES
NO
10.
If YES, enter the amount he/she owes you/your organization, the date(s) was/will be incurred and describe why the debt was/will
be incurred.
INFORMATION ABOUT INSTITUTIONS, AGENCIES AND BANKS APPLYING TO BE REPRESENTATIVE PAYEE
11.
(a) Enter the name of the institution
(b) Enter the EIN of the institution
INFORMATION ABOUT INDIVIDUALS APPLYING TO BE REPRESENTATIVE PAYEE
12.
Enter: YOUR NAME
DATE OF BIRTH
SOCIAL SECURITY NUMBER
ANY OTHER NAME YOU HAVE USED
OTHER SSN'S YOU HAVE USED
How long have you known the claimant?
13.
14.
If the claimant lives with you, who takes care of the claimant when work or other activity takes you away from home?
What is his/her relationship to the claimant?
15.
(a) Main source of your income
Employed (answer (b) below)
Self-employed (Type of Business
)
Social Security benefits (Claim Number
)
Pension (describe
)
Supplemental Security Income payments (Claim Number
)
AFDC (County & State
)
Other Welfare (describe
)
Other (describe
)
(b) Enter your employer's name and address:
How long have you been employed by this employer?
(If less than 1 year, enter name and address of previous employer in Remarks.)
16.
(a) Have you ever been convicted of a felony?
YES
NO
If YES: What was the crime?
On what date were you convicted?
What was your sentence?
If imprisoned, when were you released?
If probation was ordered, when did/will your probation end?
(b) Have you ever been convicted of any offense under federal or state law which resulted in imprisonment for more than one
year?
YES
NO
If YES:What was the crime?
On what date were you convicted?
What was your sentence?
If imprisoned, when were you released?
If probation was ordered, when did/will your probation end?
Form SSA-11-BK (08-2009)
EF (08-2009)
Page 3
Do you have any unsatisfied FELONY warrants (or in jurisdictions that do not define crimes as felonies, a crime punishable by
17.
death or imprisonment exceeding 1 year) for your arrest?
YES
NO
__________________________________________________________________________
If YES: Date of Warrant
___________________________________________________________
State where warrant was issued
18.
How long have you lived at your current address? (Give Date MM/YY)
_________________________________________
REMARKS: (This space may be used for explaining any answers to the questions. If you need more space, attach a separate sheet.)
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING THIS FORM
I/my organization:
• Must use all payments made to me/my organization as the representative payee for the claimant's current needs or (if not currently
needed) save them for his/her future needs.
• May be held liable for repayment if I/my organization misuse the payments or if I/my organization am/is at fault for any overpayment
of benefits.
• May be punished under Federal law by fine, imprisonment or both if I/my organization am/is found guilty of misuse of Social Security
or SSI benefits.
I/my organization will:
• Use the payments for the claimant's current needs and save any currently unneeded benefits for future use.
• File an accounting report on how the payments were used, and make all supporting records available for review if requested by the
Social Security Administration.
• Reimburse the amount of any loss suffered by any claimant due to misuse of Social Security or SSI funds by me/my organization.
• Notify the Social Security Administration when the claimant dies, leaves my/my organization's custody or otherwise changes his/her
living arrangements or he/she is no longer my/my organization's responsibility.
• Comply with the conditions for reporting certain events (listed on the attached sheets(s) which I/my organization will keep for my/my
organization's records) and for returning checks the claimant is not due.
• File an annual report of earnings if required.
• Notify the Social Security Administration as soon as I/my organization can no longer act as representative payee or the claimant no
longer needs a payee.
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.
(Month, day, year)
DATE
SIGNATURE OF APPLICANT
Telephone number(s) at which you
Signature (First name, middle initial, last name) (Write in ink)
may be contacted during the day
SIGN
HERE
Print Your Name & Title (if a representative or employee of an institution/organization)
(Number and street, Apt. No., P.O. Box, or Rural Route)
Mailing Address
City and State
Zip Code
Name of County
(Number and street, Apt. No., P.O. Box, or Rural Route)
Residence Address
City and State
Zip Code
Name of County
Witnesses are only required if this application has been signed by mark (X) above. If signed by mark (X), two witnesses
to the signing who know the applicant making the request must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS
ADDRESS (Number and street, City, State and ZIP Code)
ADDRESS (Number and street, City, State and ZIP Code)
Form SSA-11-BK (08-2009)
EF (08-2009)
Page 4
SOCIAL SECURITY
Information for Representative Payees Who Recieve Social Security Benefits
YOU MUST NOTIFY THE SOCIAL SECURITY ADMINISTRATION PROMPTLY IF ANY OF THE FOLLOWING EVENTS
OCCUR AND PROMPTLY RETURN ANY PAYMENT TO WHICH THE CLAIMANT IS NOT ENTITLED:
• the claimant DIES (Social Security entitlement ends the month before the month the claimant dies);
• the claimant MARRIES, if the claimant is entitled to child's, widow's, mother's, father's, widower's or parent's benefits, or to wife's
or husband's benefits as divorced wife/husband, or to special age 72 payments;
• the claimant's marriage ends in DIVORCE or ANNULMENT, if the claimant is entitled to wife's, husband's or special age 72 payments;
• the claimant's SCHOOL ATTENDANCE CHANGES if the claimant is age 18 or over and entitled to child's benefits as a full time
student
• the claimant is entitled as a stepchild and the parents DIVORCE (benefits terminate the month after the month the divorce becomes
final);
• the claimant is under FULL RETIREMENT AGE (FRA) and WORKS for more than the annual limit (as determined each year) or more
than the allowable time (for work outside the United States);
• the claimant receives a GOVERNMENT PENSION or ANNUITY or the amount of the annuity changes, if the claimant is entitled to
husband's, widower's, or divorced spouse's benefit's;
• the claimant leaves your custody or care or otherwise CHANGES ADDRESS;
• the claimant NO LONGER HAS A CHILD IN CARE, if he/she is entitled to benefits because of caring for a child under age 16 or who is
disabled;
• the claimant is confined to jail, prison, penal institution or correctional facility;
• the claimant is confined to a public institution by court order in connection WITH A CRIME.
• the claimant has an UNSATISFIED FELONY WARRANT (or in jurisdictions that do not define crimes as felonies, a crime punishable by
death or imprisonment exceeding 1 year) issue for his/her arrest;
• the claimant is violating a condition of probation or parole under State or Federal law.
IF THE CLAIMANT IS RECEIVING DISABILITY BENEFITS, YOU MUST ALSO REPORT IF:
• the claimant's MEDICAL CONDITION IMPROVES;
• the claimant STARTS WORKING;
• the claimant applies for or receives WORKER'S COMPENSATION BENEFITS, Black Lung Benefits from the Department of Labor, or a
public disability benefit;
• the claimant is DISCHARGED FROM THE HOSPITAL (if now hospitalized).
IF THE CLAIMAINT IS RECEIVING SPECIAL AGE 72 PAYMENTS, YOU MUST ALSO REPORT IF:
• the claimant or spouse becomes ELIGIBLE FOR PERIODIC GOVERNMENTAL PAYMENTS, whether from the U.S. Federal government
or from any State or local govenment;
• the claimant or spouse receives SUPPLEMENTAL SECURITY INCOME or PUBLIC ASSISTANCE CASH BENEFITS;
• the claimant or spouse MOVES outside the United States (the 50 States, the District of Columbia and the Northern Marian Islands).
In addition to these events about the claimant, you must also notify us if:
• YOU change your address;
• YOU are convicted of a felony or any offense under State or Federal law which results in imprisonment for more than 1 year;
• YOU have a UNSATISFIED FELONY WARRANT (or in jurisdictions that do not define crimes as felonies, a crime punishable by death or
imprisonment exceeding 1 year) issued for your arrest.
BENEFITS MAY STOP IF ANY OF THE ABOVE EVENTS OCCUR. You should read the informational booklet we will send you to see how
these events affect benefits. You may make your reports by telephone, mail, or in person.
REMEMBER:
• payments must be used for the claimant's current needs or saved if not currently needed;
• you may be held liable for repayment of any payments not used for the claimant's needs or of any over payment that occured due to
your fault;
• you must account for benefits when so asked by the Social Security Administration. You will keep records of how benefits were
spent so you can provide us with correct accounting;
• to tell us as soon as you know you will no longer be able to act as representative payee or the claimant no longer needs a
payee.
Keep in mind that benefits may be deposited directly into an account set up for the claimant with you as payee. As soon as you set up
such an account, contact us for more information about receiving the claimant's payments using direct deposit.
Form SSA-11-BK (08-2009)
EF (08-2009)
Page 5

Download Form SSA-11-BK Request to Be Selected as Payee

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Where to File SSA-11-BK?

The form SSA 11-BK can be filed during the face-to-face interview at the SSA office. If the form is mailed, faxed or dropped, the interview must follow anyway.

How to Fill out SSA-11-BK?

The instructions for filling out the Social Security request to be selected as payee can be found below.

Form SSA-11-BK Instructions

  1. Heading. Enter your name and social security number and the name of the beneficiary and their social security number;
  2. Item 1. Check the box if you are filing a request for direct payment. This item applies to the beneficiary only;
  3. Item 2. Provide an explanation as to why the beneficiary requires a representative payee. If they are a minor child, check the box;
  4. Item 3. Provide a reason why you should be chosen as a representative payee for that person. It the provided space is not enough, use the Remarks section;
  5. Item 4. Check the applicable box, indicating a way you will know about the beneficiary's needs;
  6. Item 5. Specify, whether the beneficiary has a court-appointed legal guardian. If the answer is positive, provide the name, address, phone number and title of this person and the date they were appointed. Describe the circumstances of appointment;
  7. Item 6a. Check the applicable box indicating the beneficiary's place of residence;
  8. Item 6b. Check the item if the beneficiary lives with other people. Provide their names and the relationship to the beneficiary;
  9. Item 6c. This item applies if the beneficiary lives in an institution. Provide the name, mailing address and phone number of this institution;
  10. Item 6d. Check the applicable box indicating whether the beneficiary's living arrangements are to be changed in the next year. Provide an explanation in the Remarks section;
  11. Item 7. This item should be filled if the applicant desires to become a representative payee of a minor child and they are not the child's parent. Specify whether the child has a living natural or adoptive parent. If the answer is positive, provide their name, address, phone number and indicate whether the parent shows interest in the child. Provide an explanation;
  12. Item 8. Enter the names and addresses or phone numbers of people who show active interest in the beneficiary. Provide the relationship of the beneficiary to these people and give a brief description of how the interest is displayed;
  13. Item 9. Check the box indicating your relationship to the beneficiary. If you checked any box in (a) option, complete only items 10 and 11 and sign the form. If any other option is chosen, skip these items and go to item 12;
  14. Item 10. Indicate, whether the beneficiary owes you or the organization you represent any money. If they do, provide the information about the debt: its amount, the date it occurred and how it is going to be incurred;
  15. Item 11. Enter the name of the institution, agency or bank you represent and the Employer Identification Number (EIN) of the organization;
  16. Item 12. Provide your name, date of birth, social security number, names and social security numbers you used in the past, if any;
  17. Item 13. Provide information about how long you have known the beneficiary;
  18. Item 14. Provide the information about the person taking the beneficiary to work or any other outside activity, if they live with you. Enter the relationship of this person with the beneficiary;
  19. Item 15a. Check the box, indicating your main source of income;
  20. Item 15b. Enter the name and address of your employer if you are employed. Enter the duration of your employment;
  21. Item 16a. Check the box, indicating, whether you have ever been convicted of a felony. The positive answer must be followed by the information about the crime: when you were convicted, what was the sentence, were you imprisoned and if you were - when you were released, and if prohibition was ordered - when it will end;
  22. Item 16b. Indicate, whether you have ever been imprisoned for more than one year. If you were, provide information about the crime, the sentence, when were you released and when the prohibition will end, in case it was ordered;
  23. Item 17. Indicate whether you have any unsatisfied felony warrants. If you have, enter the date of the warrant and the place it was issued;
  24. Item 18. Enter the date you moved into your current house in MM/YY format;
  25. Sign and date the form. Provide your phone number. Enter your mailing address and residence address. If you are a representative of an organization, print your name and title.
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