Beneficiary Interview and Auditor's Observations (original)

FORM APPROVED

OMB NO. 0960-0630

BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS

Privacy Act and Paperwork Reduction Act Statements

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.

Beneficiary Information

Name: ___________________ SSN: _________________ Age: _______

Beneficiary Interview (ask the beneficiary and/or caregiver the following questions)

1. Are you satisfied with the living arrangements provided by the rep payee?

• Yes

• No

If no, obtain the beneficiary’s explanation

2. Are you satisfied with the clothing and personal items provided by the rep payee?

• Yes

• No

If no, obtain the beneficiary’s explanation

3. Are you satisfied with the food provided by the rep payee?

• Yes

• No

If no, obtain the beneficiary’s explanation.

4. Does the rep payee pay your bills in a timely manner?

• Yes

• No

If no, obtain the beneficiary’s explanation

5. 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

6. Other comments or observations of the beneficiary

Auditor’s Observations

1. Does the living quarters and housing appear to be adequate?

• Yes

• No

If no, explain

2. Does the beneficiary’s wardrobe and clothes appear to be adequate?

• Yes

• No

If no, explain

3. Does it appear that the beneficiary is provided adequate food and medicine (if applicable)?

• Yes

• No

If no, explain

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