Ssa-11-bk (3-2006)

Form SSA-11-BK (03-2006).pdf

Application to Act as Representative Payee

SSA-11-BK (3-2006)

OMB: 3220-0052

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3220-0052 can be found here:

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TOE 250

SOCIAL SECURITY ADMINISTRATION

FOR SSA USE ONLY
Name or

sym,

Program

Date of

~ i ~ ~ , , Type

Gdn.

Form Approved
OMB NO. 0960-0014

Cus.

Inst.

FOR SSA USE ONLY

Nam.

REQUEST TO
BE SELECTED
A S PAYEE
DISTRICT OFFICE CODE
STATE AND COUNTY CODE:
PRINT IN INK:
The name o f the NUMBER HOLDER

SOCIAL SECURITY NUMBER

The name of the PERSON(S) (if different from above) for w h o m you are filing (the
"claimant(s)")

SOCIAL SECURITY NUMBERE)

Answer item 1 ONLY if you are the claimant and want your benefits paid directly to you.

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, BLACK LUNG OR SPECIAL VETERANS
BENEFITS FOR THE CLAIMANTIS) NAMED ABOVE BE PAID TO ME A S REPRESENTATIVE PAYEE.
2.

Explain why you think the claimant is not able to handle hislher own benefits.
(In your answer, describe how helshe manages any money helshe receives now.)

Claimant is a minor child.

Explain why you would be the best representative payee. (Use Remarks if you need more space.)

If you are appointed payee, how will you know about the claimant's needs?
Live with me or in the institution I represent.

U Daily visits.
Visits at least once a week.
By other means. Explain:

Does the claimant have a court-appointed legal guardian?

YES

IF YES, enter the legal guardian'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 (03-2006)
Destroy Prior Editions

EF (03-2006)

Page 1

Where does the claimant live?
-

1Alone

7
7
7
7
1

In my home (Go to (b).)

In a public institution (Go to (c).)

With a relative (Go t o (b).)

In a private institution (Go to (c).)

With someone else (Go t o (b).)

In a nursing home (Go t o (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 anv other people who live with the claimant.

NAME

RELATIONSHIP

Mailing:

Telephone Number:

(dl Do you ex ect 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
mace.)

If you are applying on behalf of minor child(ren) and you are not the parent,

Does the childhen) have a living natural or adoptive parent?
If YES, enter:

YES

(a) Name of parent
(b) Address of parent
(c) Telephone number
(d) Does the parent show interest in the child?
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

ADDRESSIPHONE NO.

RELATIONSHIP

DESCRIBE SUPPORTIINTEREST

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

n StateILocal
Private non-profit
-

Private proprietary institution. Is the institution licensed under State law?
IF (a) ABOVE CHECKED, COMPLETE ONLY QUESTIONS 1 0 AND 11 AND SIGN THE FORM ON PAGE 4.
(b)

Parent

(c)

Spouse

(dl
(el

Other Relative - Specify

nLegal Representative

If)

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 (03-2006)

EF (03-2006)

Page 2

YES

INFORMATION A B O U T INSTITUTIONS, AGENCIES AND B A N K S APPLYING T O BE REPRESENTATIVE PAYEE
10.

(a) Enter the name of the institution
(b) Enter the EIN of the institution

1 1.

Is the claimant indebted t o your institution for past care and maintenance?
NO
YES
If YES, give the amount of the debt, the date(s) the debt was incurred and the description of the debt.

INFORMATION A B O U T INDIVIDUALS APPLYING T O 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

13.

How long have you known the claimant?

14.

YES
NO
Does the claimant owe you any money now or will helshe owe you money in the future?
If YES, enter the amount helshe owes you, the date(s) the debt waslwill be incurred and describe why the debt waslwill be
incurred.

15.

If the claimant lives with you, who takes care of the claimant when work or other activity takes you away from home? What is
hislher relationship to the claimant?

16.1 ( a ) M a i n source of your income

Employed (answer (b) below)
I U
U Self-employed (Type of Business

)

Social Security or Black Lung benefits (Claim Number

Pension (describe

U Supplemental Security Income payments (Claim Number

U
U
1

1
17.

AFDC (County & State

1
1

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.)
(a) Have you ever been convicted of a felony?

YES

If YES: What was the crime?

I
I
1
I

On what date were you convicted?
What was your sentence?
If imprisoned, when were you released?
If probation was ordered, when didlwill 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

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 didlwill vour probation end?

Form SSA-1 1-BK (03-2006)

EF (03-2006)

Page 3

18, D o y o u h a v e a n y unsatisfied FELONY warrants (or i n jurisdictions t h a t d o n o t define crimes as felonies, a crime
punishable b y death or imprisonment exceeding 1 year) f o r your arrest?
YES
NO

I f YES: D a t e o f Warrant
S t a t e w h e r e w a r r a n t w a s issued
19.

H o w long h a v e y o u lived a t your current address? (Give D a t e M M I Y Y )
(If less t h a n 1 year, enter previous address i n Remarks)

REMARKS: (This space may be used for explaining any answers to the questions. If you need more space, attach a separate sheet.)

PLEASE READ T H E FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING THIS F O R M
Ilmy organization:
Must use all payments made to melmy organization as the representative payee for the claimant's current needs or (if not currently
needed) save them for hislher future needs.
* May be held liable for repayment if Ilmy organization misuse the payments or if Ilmy organization amlis at fault for any overpayment
of benefits.
* May be punished under Federal law by fine, imprisonment or both if Ilmy organization amlis found guilty of misuse of Social Security
or SSI benefits.
Ilmy 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 t o misuse of Social Security or SSI funds by melmy organization.
Notify the Social Security Administration when the claimant dies, leaves mylmy organization's custody or otherwise changes hislher
living arrangements or helshe is no longer mylmy organization's responsibility.
Comply with the conditions for reporting certain events (listed on the attached sheets(s) which Ilmy organization will keep for mylmy
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 Ilmy organization can no longer act as representative payee or the claimant no
longer needs a payee.
. .
I declare under p e n a l t y o f perjury t h a t I h a v e examined all t h e i n f o r m a t i o n o n t h i s form, a n d o n a n y a c c o m p a n y i n g
statements o r forms, a n d it i s t r u e a n d c o r r e c t t o t h e b e s t o f my knowledge.

DATE (Month, day, year)

SIGNATURE O F APPLICANT

Telephone number(s) at Which You
May Be Contacted During the Day

Signature (First name, middle initial, last name) (Write in ink)

HERE

Print Your Name & Title (if a representative or employee of an institution/organization)
Mailing Address (Number and street, Apt. No., P. 0.Box, or Rural Route)
Zip Code

City and State

Name of County

Residence Address (Number and street, Apt. No., P. 0.Box, or Rural Route)
City and State

Zip Code

Name of County

Witnesses are o n l y required i f this application has b e e n signed b y m a r k (X) above. I f signed b y m a r k (XI, t w o witnesses
t o t h e signing w h o k n o w t h e applicant m a k i n g t h e request m u s t s i g n below, giving their full addresses.
1. SIGNATURE OF WITNESS

2. SIGNATURE OF WITNESS

ADDRESS (Number and street, City, State and ZIP Code)

Form SSA-11 -BK (03-2006)

EF (03-2006)

Page 4

SOCIAL SECURITY
Information for Representative Payees Who Receive 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 a divorced wifelhusband, 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 benefits;
the claimant leaves your custody or care or otherwise CHANGES ADDRESS;
the claimant NO LONGER HAS A CHILD IN CARE, if helshe 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) issued for hislher 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 CLAIMANT 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 government;
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 Mariana 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 an 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 t o 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 o f any payments not used for the claimant's needs or of any
over payment that occurred due t o your fault;
you must account for benefits when so asked by the Social Security Administration. You will keep
records of h o w benefits were spent so you can provide us w i t h a correct accounting;
t o tell us as soon as you k n o w you will no longer be able t o 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 w i t h 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-1 1-BK (03-2006) EF (03-2006)

Page 5

A REMINDER TO PAYEE APPLICANTS
BEFORE YOU RECEIVE A
DECISION NOTICE

DATE REQUEST RECEIVED

SSA OFFICE

TELEPHONE NUMBERE)
TO CALL IF YOU HAVE A
QUESTION OR SOMETHING
TO REPORT
DECISION NOTICE

RECEIPT FOR YOUR REQUEST
Your request for Social Security benefits on behalf of the
individual(s) named below has been received and will be
processed as quickly as possible.

you - or someone for you - should report the change.
The changes to be reported are listed on the reverse.

You should hear from us withindays after you have
given us all the information we requested. Some claims
may take longer if additional information is needed.

Always give us the claim number of the beneficiary when
writing or telephoning about the claim.

In the meantime, if you change your address, or if there is
some other change that may affect the benefits payable,

If you have any questions about this application, we will
be glad to help you.

BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER

THE PRIVACY ACT
We are required by section 205(j) and 205(a) of the Social Security Act t o ask you t o give us the information on this
form. This information is needed t o determine if you are qualified to serve as representative payee. Although responses
t o these questions are voluntary, you will not be named representative payee unless you give us the answers t o these
questions.
Sometimes the law requires us t o give out the facts on this form without your consent. We must release this
information to another person or government agency if Federal law requires that w e do so or to do the research and
audits needed 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.
Explanati~ilabout 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.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. 5 3507, as
amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless w e
display a valid Office of Management and Budget control number. We estimate that it will take about 10.5 minutes to
read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies i n your telephone directory or
you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 6401
Security Blvd., Baltimore, MD 21235-6401. Send on/y comments relating to our time estimate to this address, not the
completed form.
Form SSA-1 1-BK (03-2006) EF (03-2006)

Page 6

SUPPLEMENTAL SECURITY INCOME
Information for Representative Payees Who Receive 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 or any member of the claimant's household DIES (SSI eligibility ends with the month in which the
claimant dies);
the claimant's HOUSEHOLD CHANGES (someone moves inlout of the place where the claimant lives);
the claimant LEAVES THE U.S. (the 5 0 states, the District of Columbia, and the Northern Mariana Islands) for 30
consecutive days or more;
the claimant MOVES or otherwise changes the place where helshe actually lives (including adoption, and
whereabouts unknown);
the claimant is ADMITTED TO A HOSPITAL, skilled nursing facility, nursing home, intermediate care facility, or
other institution;
the INCOME of the claimant or anyone in the claimant's household CHANGES (this includes income paid by
an organization or employer, as well as monetary benefits from other sources);
the RESOURCES of the claimant or anyone in the claimant's household CHANGES (this includes when conserved
funds reach over $2,000);
the claimant or anyone in the claimant's household MARRIES;
the marriage of the claimant or anyone in the claimant's household ends in DIVORCE or ANNULMENT;
the claimant SEPARATES from hislher spouse;
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) issued for hislher arrest;
the claimant is violating a condition of probation or parole under State or Federal law.
IF THE CLAIMANT IS RECEIVING PAYMENTS DUE TO DISABII-ITY OR BLINDNESS, YOU MUST ALSO REPORT IF:
the claimant's MEDICAL CONDITION IMPROVES;
the claimant GOES TO WORK;
the claimant's VISION IMPROVES, if the claimant is entitled due to blindness;
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 an 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.
PAYMENT MAY STOP IF ANY OF THE ABOVE EVENTS OCCUR. You should read the informational booklet we will send
you t o 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. (Savings are considered
resources and may affect the claimant's eligibility t o payment.);
you may be held liable for repayment of any payments not used for the claimant's needs or of any overpayment
that occurred 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 a correct accounting;
t o let us know as soon as you know you are unable to continue as representative payee or the claimant no longer
needs a payee;
you will be asked to help in periodically redetermining the claimant's continued eligibility or payment. You will
need t o keep evidence t o help us with the redetermination (e.g., evidence of income and living arrangements).
you may be required t o obtain medical treatment for the claimant's disabling condition if helshe is eligible under
the childhood disability provision.
Keep in mind that payments 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-1 1-BK (03-2006) EF (03-2006)

Page

A REMINDER TO PAYEE APPLICANTS
BEFORE YOU RECEIVE A
DECISION NOTICE
TELEPHONE NUMBER(S1
TO CALL IF YOU HAVE A
QUESTION OR SOMETHING
TO REPORT

SSA OFFICE

DATE REQUEST RECEIVED

AFTER you RECEIVE A
DECISION NOTICE

RECEIPT FOR YOUR REQUEST
Your request for SSI payments on behalf of the
individual(s1 named below has been received and will be
processed as quickly as possible.

y o u - or someone for you - should report the change.
The changes t o be reported are listed on the reverse.

You should hear f r o m us withindays after you have
given us all the information w e requested. Some claims
may take longer if additional information is needed.

Always give us the claim number of the beneficiary when
writing or telephoning about the claim.

In the meantime, if y o u change your address, or if there is
some other change that may affect t h e benefits payable,

If you have any questions about this application, w e will
be glad t o help you.

BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER

THE PRIVACY A C T
W e are required b y section 205(j) and 205(a) of the Social Security A c t t o ask you t o give us the information o n this
form. This information is needed t o determine if you are qualified t o serve as representative payee. Although responses
t o these questions are voluntary, you will n o t be named representative payee unless you give us the answers t o these
questions.
Sometimes the law requires us t o give out the facts on this form without your consent. We must release this
information t o another person or government agency if Federal l a w requires that w e do so or t o do the research and
audits needed t o administer or improve our representative payee program.
We may also use t h e information you give us w h e n w e match records b y computer. Matching programs compare our
records w i t h those of other Federal, state or local government agencies. Many agencies may use matching programs t o
find or prove that a person qualifies for benefits paid b y the Federal government. The l a w allows us t o do this even if
you do n o t agree t o it.
Explanation about these and other reasons w h y information y o u provide us may be used or given o u t are available in
Social Security offices. If y o u want t o learn more about this, contact any Social Security office.

Paperwork Reduction A c t Statement - This information collection meets the requirements o f 44 U.S.C. 5 3507, as
amended by section 2 of the Paperwork Reduction A c t of 1995. You do n o t need t o answer these questions unless w e
display a valid Office o f Management and Budget control number. W e estimate that it will take about 10.5 minutes t o
read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM T O YOUR
LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies i n your telephone directory or
you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 6407
Security Blvd., Baltimore, MD 2 1235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
Form SSA-11-BK (03-2006)

EF (03-20061

Page 8

BLACK LUNG BENEFITS
Information for Representative Payees Who Receive Black Lung 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;
the claimant receives STATE WORKER'S COMPENSATION based on the miner's disability, or the
amount of such compensation changes;
the miner receives UNEMPLOYMENT INSURANCE;
the claimant IS WORKING or RETURNS TO WORK;
the claimant MARRIES or REMARRIES, i f the claimant is entitled t o child's, widow's, brother's or
sister's benefits;
the claimant begins t o RECEIVE SUPPORT PAYMENTS from hislher spouse, if t h e claimant is entitled
t o brother's or sister's benefits;
the claimant is ADOPTED, if the claimant is entitled t o child's benefits;
the claimant's MEDICAL COhlDlTlON IMPROVES, i f the claimant is entitled t o disabled child's brother's
or sister's benefits;
the claimant is age 18 t o 23 and STOPS ATTENDING SCHOOL, if the claimant is receiving child's,
sister's or brother's benefits.
In addition t o these events about t h e claimant, you must also notify us if:
YOU change your address;
YOU are convicted of a felony or any offer under State or Federal law which results in imprisonment
for more than 1 year;
YOU have an 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 M A Y STOP IF' ANY OF THE ABOVE EVENTS OCCUR. You should read the informational booklet
w e will send you t o see h o w these events affect benefits. You may make your reports b y telephone, mall 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 o f any payments not used for the claimant's needs or of any
overpayment that occurred due t o your fault;
you must account for benefits when so asked by the Social Security Administration. You will keep
records o f h o w benefits were spent so you can provide us w i t h a correct accounting;
t o let us know as soon as you k n o w you are unable to continue 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 w i t h you as
payee. A s soon as you set up such an account, contact us for more information about receiving the
claimant's payments using direct deposit.

Form SSA-1 1-BK (03-2006) EF (03-2006)

Page

A REMINDER TO PAYEE APPLICANTS
BEFORE YOU RECEIVE A
DECISION NOTICE

SSA OFFICE

DATE REQUEST RECEIVED

TELEPHONE NUMBER(S1
TO CALL IF YOU HAVE A
QUESTION OR SOMETHING AFTER y o u RECEIVE A
TO REPORT
DECISION NOTICE

RECEIPT FOR YOUR REQUEST
Your request for Black Lung benefits on behalf of the
individual(s) named below has been received and will be
processed as quickly as possible.

you - or someone for you - should report the change.
The changes to be reported are listed on the reverse.

You should hear from us withindays after you have
given us all the information we requested. Some claims
may take longer if additional information is needed.

Always give us the claim number of the beneficiary when
writing or telephoning about the claim.

In the meantime, if you change your address, or if there is
some other change that may affect the benefits payable,

If you have any questions about this application, we will
be glad to help you.

BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER

THE PRIVACY ACT
We are required by section 205(j) and 205(a) of the Social Security Act to ask you to give us the information on this
form. This information is needed to determine if you are qualified to serve as representative payee. Although responses
to these questions are voluntary, you will not be named representative payee unless you give us the answers to these
questions.
Sometimes the law requires us to give out the facts on this form without your consent. We must release this
information to another person or government agency if Federal law requires that we do so or to do the research and
audits needed to administer or improve our representative payee program.
We may also use the information you give us when w e 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.
Explanation 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 t o learn more about this, contact any Social Security office.

Paperwork Reduction A c t Statement - This information collection meets the requirements of 44 U.S.C. 5 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 10.5 minutes to
read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies i n your telephone directory or
you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 6401
Security Blvd., Baltimore, MD 27235-6407. Send only comments relating to our time estimate to this address, not the
completed form.
Form SSA-11 -BK (03-2006) EF (03-2006)

Page 10

SPECIAL BENEFITS FOR WORLD WAR II VETERANS
Information for Representative Payees Who Receive Special Benefits for WW II Veterans
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 (special veterans entitlement ends the month after the claimant dies);
the claimant returns to the United States for a calendar month or longer;
the claimant moves or changes the place where helshe actually lives;
the claimant receives a pension, annuity or other recurring payment (includes workers' compensation,
veterans benefits or disability benefits), or the amount of the annuity changes;
the claimant is or has been deported or removed from U.S.;
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) issued for hislher arrest;
the claimant is violating a condition of probation or parole under State or Federal law.
In addition t o 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 an 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 can make your reports by telephone,
mail or in person. You can contact any U.S. Embassy, Consulate, Veterans Affairs Regional Office in the
Philippines or any U.S. Social Security Office.

Form SSA-1 1-BK (03-2006) EF (03-2006)

Page 1 1

A REMINDER TO PAYEE APPLICANTS
BEFORE YOU RECEIVE A
DECISION NOTICE

SSA OFFICE

DATE REQUEST RECEIVED

TELEPHONE NUMBER(SJ
TO CALL IF YOU HAVE A
QUESTION OR SOMETHING AFTER you RECEIVE A
TO REPORT
DECISION NOTICE

RECEIPT FOR YOUR REQUEST
Your request for Special benefits for WW II Veterans on
behalf of the individual(s1 named below has been received
and will be processed as quickly as possible.

you - or someone for you - should report the change.
The changes to be reported are listed on the reverse.

You should hear from us withindays after you have
given us all the information we requested. Some claims
may take longer if additional information is needed.

Always give us the claim number of the beneficiary when
writing or telephoning about the claim.

In the meantime, if you change your address, or if there is
some other change that may affect the benefits payable,

If you have any questions about this application, we will
be glad to help you.

BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER

THE PRIVACY ACT
We are required by section 205(j) and 205(a) of the Social Security A c t to ask you to give us the information on this
form. This information is needed to determine if you are qualified to serve as representative payee. Although responses
to these questions are voluntary, you will not be named representative payee unless you give us the answers t o these
questions.
Sometimes the law requires us t o give out the facts on this form without your consent. We must release this
rnformation to another person or government agency if Federal law requires that we do so or to do the research and
audits needed to administer or improve our representative payee program.
We may also use the information you give us when w e 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.
Explanation 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 t o learn more about this, contact any Social Security office.

Paperwork Reduction A c t 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 control number. We estimate that it will take about 10.5 minutes to
read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies i n your telephone directory or
you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 6407
Security Blvd., Baltimore, MD 2 7235-640 7. Send only comments relating to our time estimate to this address, not the
completed form.
Form SSA-11 -BK (03-2006)

EF (03-2006)

Page 12

File Type	application/pdf
File Modified	2007-04-04
File Created	2007-04-04