Current Non-Revised SSA-6234

Social Security Administration
Representative Payee Report
Why You Received
This Form

We must regularly review how representative payees, including parents, stepparents, and
grandparents with custody of minor children, used the benefits they received on behalf of the
Social Security and/or Supplemental Security Income (SSI) beneficiaries. We do this to
ensure the benefits are used to meet the child(ren)'s needs.
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. You should use these records to answer the questions on the enclosed reporting
form. You must complete this form if you received any Social Security and/or SSI payments
during the 12-month report period shown on the form. You must also complete the form if
you wish to continue to receive payments for the child(ren) in your custody. It is called
Representative Payee Report, SSA-6234-F6.
You should keep these records (e.g., bank statements and canceled checks) for two years
from the time you complete the form. Do not submit any records with the completed form. If
we have any questions or require proof, we will contact you.
The name(s) of the child(ren) we are asking about are shown in item 3 on the form. If you
receive benefits for children not named in item 3, we will send you another form. Use this
form only for the child(ren) named in item 3.

What You Need
To Do

Please read the instructions below before completing the form. Then, complete the form
and send it to us in the enclosed envelope within 30 days.

General
Instructions

To help us process your report, please follow these instructions:
1.
2.
3.
4.

Use black ink or a #2 pencil.
Keep your numbers and “X’s” inside the boxes.
Do not use dollar signs.
Show money amounts in dollars only. Do not show cents.
For example, show $1,540.70 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.
7. Be sure you, the representative payee, sign the form.

Some
Definitions
To Help You

Benefits - The Social Security and/or SSI money that you receive.
Payee - You. The person who receives Social Security and/or SSI benefits for someone else.
Beneficiary - The person for whom you receive Social Security and/or SSI benefits.
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.

FORM SSA-6234-F6 (6-2006) ef (6-2006)

1

Continued on the Reverse

HOW TO FILL OUT THE FORM
QUESTION 1 Beneficiary
Custody
Changes

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 period. Place an “X” in the “NO” box if different
peopleor different institutions took care of the beneficiary during any
part of the report period. Explain the change and provide the
beneficiary’s

QUESTION 2 Accounting
For Benefits

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.

A.

Who Decided
How Benefits
Were Used?

Place an “X” in the “YES” box if you (the payee) decided how the benefits
were spent or saved. Place an “X” in the “NO” box if the beneficiary or
someone else decided how to use the money, and explain under REMARKS.

B.

Did You
Charge A Fee?
And
How Much Did
You Collect?

Place an “X” in the “YES” box if you charged the beneficiary a
fee for payee or guardianship services you provided during the
report period and show the total amount of benefits you collected
from the beneficiary. If you did not charge the beneficiary a fee,
place an “X” in the “NO” box and go to 2.C. below.

C.

Food and
Housing

Show the total amount of benefits spent for food and housing for the
beneficiary during the report period.

D.

Personal
Items

Show the total amount of benefits spent on clothing, medical/dental care,
education, and recreational items like toys, movies, cameras, radios, candy,
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.

C.

Unused
Benefits

Show the amount of benefits you saved for the child(ren) at the end of the
report period including any interest earned. Show zeroes if you did not save
any of the benefits.

FORM SSA-6234-F6 (6-2006) ef (6-2006)

2

QUESTION 3 Savings Information

Answer this question if you showed an amount in 2E.

A.

Type Of
Account

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.

B.

Title Of
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 “Other” box if the account title is
different or if you have not placed the savings in any type of
account.

QUESTION 4 Other Savings/
Account Titles

Answer this question only if you checked “OTHER” in 3.A. or 3.B.

A.

Type Of
Account

Indicate whether the saved benefits are in cash, Treasury Bills, or some other
investment such as mutual funds, or property. For mutual funds, be sure to
show the name of the fund in your response (e.g., "XYZ Growth" mutual
fund).

B.

Title Of
Account

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.

5.

Payee’s
Signature

Sign your name in this block. If the payee is an organization, an
authorized person must sign the form. This includes the signature
of those employees designated to complete the report on behalf of
the payee.

6.

Relationship
To The
Beneficiary

Show your relationship to the beneficiary. If you are the beneficiary’s
court-appointed legal guardian, show “legal guardian.” If you represent
an organization, show your job title (e.g., administrator, bookkeeper,
etc.).

Continued on the Next Page
FORM SSA-6234-F6 (9-2003) ef (1-2005)

3

The law sometimes requires us to give out
the facts on this form without your consent.
The information must be released to another
person or government agency if Federal law
requires the information for research and
audits in order to administer or improve our
representative payee program.
We may also use the information you give us
when we match records by computer.
Matching programs compare our records with
those of other Federal, State, or local
government agencies. Many agencies may use
matching programs to find or prove that a
person qualifies for benefits paid by the
Federal government. The law allows us to do
this even if you do not agree to it.
Explanations about these and other reasons
why information you provide us may be used
or given out are available in Social Security
offices. If you want to learn more about this,
contact any Social Security office.
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 control number.
We estimate that it will take about 15
minutes to read the instructions, gather the
necessary facts, and answer the questions.
You may send comments on our time estimate
above to: SSA, 1338 Annex Building,
Baltimore, MD 21235. Send only comments
relating to our time estimate to this address,
not the completed form.
If You Have Any Questions
If you have any questions, please call us at
1-800-772-1213. We can answer most
questions over the phone. If you prefer to visit
one of our offices, please use 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.

Your Responsibilities As
Representative Payee
We appreciate your services as representative
payee. As payee, you must use the Social
Security and/or SSI benefits you receive for
the care and well being of the beneficiary. You
need to know the beneficiary’s needs so that
you can use the money properly.
In addition to reporting on the use of benefits,
you must report any changes which may
affect the beneficiary’s eligibility for benefits,
or the payment amount. You should report
the changes as soon as possible by calling
SSA at 1-800-772-1213, or by calling or
writing your local SSA office. For example,
you must tell us if the beneficiary:
• dies,
• moves (especially if he/she enters or leaves
a hospital or other institution),
• marries,
• starts or stops working,
• is imprisoned,
• is adopted,
• no longer needs a payee, or
• you are no longer responsible for the
beneficiary.
If you are payee for a child receiving SSI
benefits, we may ask you for proof that the
child is receiving medical treatment for
his/her disabling condition. We may ask for
this information at the time we review the
child’s case. If we do ask for this information,
you must give it to us.
The Privacy Act And Paperwork
Reduction Act Statements
We are required by sections 205(j) and
1631(a) of the Social Security Act to ask you
to complete this report. The information you
provide enables SSA to account for the
beneficiary’s payments, and ensures that
beneficiary needs are being met. If you do
not complete and return this report, we may
not be able to continue sending the beneficiary’s
payments to you.

FORM SSA-6234-F6 (6-2006) ef (6-2006)

4

Representative Payee Report
FORM APPROVED
OMB NO. 0960-0691

PAYEE'S NAME AND ADDRESS

REPORT PERIOD

SOCIAL SECURITY NUMBER

FROM:

-

TO:

-

BENEFICIARY

ID

CF

FP

D

BIC

PF

TAA

TP

BSSN

FFS

-

Please review the above address and correct if neccessary.

GS

CC

PC

DAA

DOC

MFA

-

This report is about the benefits you received for the beneficiary during the report period
shown above. Please read the enclosed instructions before completing this form to help you answer
each question.

1.

Did the beneficiary continue to live alone, or with the same person, or in the
same institution during the report period shown above? If NO, please explain
and provide the beneficiary’s current address in REMARKS on the back of
this form.

2.

Benefits paid to you during the report period
Benefits you reported as saved on last year's report

=$
=$

Total Accountable Amount

=$

A.
B.

Did you (the payee) decide how the total accountable amount was spent or
saved?
If NO, please explain in REMARKS on the back of this form.

YES

NO

YES

NO

YES

NO

Did you (the payee) charge the beneficiary a fee for payee or
guardianship services you provided during the report period?
If YES, how much of the total accountable amount did you
collect from the beneficiary for these services during the
report period?

DOLLAR AMOUNT
(NO CENTS)

,

C.

How much of the total accountable amount did you spend for the
beneficiary’s food and housing during the report period?

,

D.

How much of the total accountable amount did you spend on other
things for the beneficiary such as clothing, education, medical and
dental expenses, recreation, or personal items during the report
period?

,

How much, if any, of the total accountable amount did you save for
the beneficiary as of the last month in the report period? If none
show zeros.

,

E.

FORM SSA-6234-F6 (6-2006) ef (6-2006)

Continued on the Reverse

FOR SSA USE ONLY

PC

3.

FO ASSISTANCE

If you showed an amount in 2.E. (front page), 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

Savings /
Checking
Account

4.

WBDOC

U.S. Savings
Bonds

Certificates of
Deposit

Collective Savings/
Checking Account

B. TITLE OF ACCOUNT
Other

Beneficiary's Name
by Your Name

Your Name for
Beneficiary's Name

Other

If you answered “Other” in 3A. or 3B. above, show the type of account or investment, or the
title of the account in which the benefits are saved.
A. TYPE OF ACCOUNT

B. TITLE OF ACCOUNT

REMARKS:

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.
PAYEE'S SIGNATURE

DATE

5.

7.

RELATIONSHIP TO BENEFICIARY OR JOB TITLE

DAYTIME TELEPHONE NUMBER(S)
(Include area code and extension)

6.
FORM SSA-6234-F6 (6-2006) ef (6-2006)

8.

(

)

Area Code

Extension