OMB NO. 0960-0630
The Privacy Act requires us to notify you that we are authorized to collect this information by sections 205 and 1631 of the Social Security Act. You do not have to provide the information requested. However, the information you provide will allow the Social Security Administration (SSA) to insure the integrity of the representative payee program and supplement other data needed to determine whether representative payees are complying with their duties. The person(s) completing the form will remain anonymous.
This information collection meets the clearance requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take you about 15 minutes to read the instructions, gather the necessary facts, and answer the questions.
Name: ___________________ SSN: _________________ Age: _______
Beneficiary Interview (ask the beneficiary and/or caregiver the following questions)
Are you satisfied with the living arrangements provided by the rep payee?
Yes
No
If no, obtain the beneficiary’s explanation
Are you satisfied with the clothing and personal items provided by the rep payee?
Yes
No
If no, obtain the beneficiary’s explanation
Are you satisfied with the food provided by the rep payee?
Yes
No
If no, obtain the beneficiary’s explanation.
Does the rep payee pay your bills in a timely manner?
Yes
No
If no, obtain the beneficiary’s explanation
Does the rep payee let you know how much money he/she has saved for you?
Yes
No
If no, obtain the beneficiary’s explanation
Other comments or observations of the beneficiary
Does the living quarters and housing appear to be adequate?
Yes
No
If no, explain
Does the beneficiary’s wardrobe and clothes appear to be adequate?
Yes
No
If no, explain
Does it appear that the beneficiary is provided adequate food and medicine (if applicable)?
Yes
No
If no, explain
File Type | application/msword |
File Title | Appendix 18 – W/P II D6 |
Author | Social Security Administration |
Last Modified By | Mandley, Tasha |
File Modified | 2009-12-29 |
File Created | 2009-12-29 |