Form SSA-8203 Statement Determining Continuing Eligibility for Supplem

Form SSA-8203-BK (03-20 18)
Discontinue Prior Editions
Social Security Administration

Page 1 of 12
0MB No. 0960-0416

D Update

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For Official Use Only
STATEMENT FOR DETERMINING CONTINUING ELIGIBILITY FOR
SUPPLEMENTA L SEC UFtlTY INCOME PAYMENTS

El SSN
Spouse's Name

Name and Address
Spouse's SSN
Click the Ones That Apply

•

•

c

O M

O N

0

0

FS-APP

FS-REF

Interviewer's Initials
When answering questions, refer to this date

DO Code

NC

IDate Received

-·

- - - - - - - -- - - - - - - - - - - - - - - - - -- - -

MAR ITAL STATUS/lRAVEL OUTSIDE THE UNITED STATES/LIVING ARRANGEMENTS
1. Since the date above, has your marital status (o r the marital status of your parents if you are a child)
changed?
2 . Since the date above, have you movt~d to a new address? If "yes ," give the new address:
ADDRESS (Number, Street, City, State, a nd Z IP Code)

•
•

Yes
Yes

•
•

No
No

DATE YOU MOV ED

3. Since the date above, have you been out~;ide the United states (the 50 States, District of Columbia , and
Northern Mariana Islands)? If "yes," please give:

I

DATE(S) L EFT (MM/DD/YYYY)

•

Yes

•

No

•

Yes

•

No

DATE(S) RETURNED (MM/DD/YYYY)

4. Since the date above, have i1ou spent a full calendar month in a hospital, nursing home, or other
institution? If "yes," please give:

I

NAME OF INSTITUTION

DATE ENTERED (MM/DD/YYYY)

DATE LEFT (MM/DD/YYYY)

ADDRESS (Number, Street, City, Si:att.=J a nd ZIP Code)

5.

-·-----

Ma rk X in the box which best describes where you live:

•

D

House
Apartment

•
•

D

Room

[ ] Nursing Home

Mobile Home

[1 Res: or f~etirement Home D

Hospita l

Rehabilitation Center

D
D

School
Other

6 . Since the date above. has anyone moved into or out of the place where you live? (including births and
deaths) If "yes," please g ive:

NAME

Yes

I
IRELATIONS1-1I,:•

t

A GE

BLIND OR
DISABLED

YES

-

I

- ---·-----· I -

(If Yes, Explain)

·---

No

INELIGIBLE CHILD
DATE
DATE
MOVED IN MOVED OUT STUDENT MARRIED INCOME
YES NO YES NO YES NO

NO

--·--------·- r - - - -i----

.

JD •

• •
[] • I
I

• • • • • •
• • • • • •

Form SSA-8203-BK (03-L018)

Page 2 of 12

- - - - -LIVING
--- -- - - - - - - - - - - - - - - - - - - -- -- ARRANGEMENTS (continued)

7. Do any other people live in i he ~;ame house·hold with you or your spouse? If "yes," please give the

!•

following information about ,hem (ir,c lL din9 children):

----·

NAME

F~~L.ATI0NSHIP

AGE AND/OR
DATE OF BIRTH

BLIND OR
DISABLED
YES

NO

-

· -- ·- ---·

(If Yes, Explain)

Yes

•

No

INELIGIBLE CHILD
STUDENT MARRIED INCOME
YES NO YES NO YES NO

• • • • • • • •
• • • • • • • •

- · - - - --- - - -- --

8. Do all of the people wrio live with you .-;~ce;ve public a.,sistance payments? (For example, welfare, TANF,
VA pension, general assistance. SSI)

•

9. a . Do you, or your spouse living with you. own or are you buying the place where you live? If "yes," give:
MONTHLY MORTG/\GE PAYMEl-l"t AMOUNT:

D Yes

b. Do you, or your spouse living with you, rent the place where you live?
c. If you are a child recipient living w1th your parents, do your parents own or rent the place where you
live?
d. Does someone else who l;ves with you own or rent the place where you live?

•
•
•

Yes

Yes
Yes

•
•
•
•

No
No
No
No

Yes O No

e. If the place where you live is remecl give,
LANDLORD'S N,\ME

-IADf)l,'=S
f

(Number, Street, City, State, and ZIP Code)

I

LANDLORD'S
PHONE

MONTHLY
RENT

l ____

f. If the place w here you live is rent:id, are you (or anyone living with you) the parent or child of your
landlord or your landlord's s~,ouse ? :f "yes:· give the name of the household member who is the related
person
g. If a. orb. is answered "ye,. " does any one who lives with you (other than your spouse) pay for or give
you money for food, mortgage or n:•r.!, property insurance or tcixes, heating fuel, gas, electricity, water,
sewerage , or garbage co,lection seM cE::·,?

--- -------·

10. Since the date on page 1, did anyo1e not I ving with you: a. Give you a free place to live?

-·

b. Help you pay the mortgage, rent 1::n;perti1 insurance, property taxes, and/or sewereage charges?
..

c. Give you or help yc u pay for ~ood, gas, electricity, heating fuel, water, and/or garbage collection
service?

-------If "yes," to a ., b., or c., complete the fo low·n·;i.

--i-- -·

SOURCE
1---------1
J NN\ /f: /A0D f~ESS {I, umber, Street, City, State, ZIP Code)

TYPE OF HELP

i

--

r--------I

I
I

·-

PHONE
NUMBER

•
•
•
•
•

Yes

Yes
Yes
Yes
Yes

•
•
•
•
•

No

No
No
No
No

'

MONTHLY MONTHS
AMOUNT RECEIVED

Form SSA-8203-BK (03-2C18)

Page 3 of 12

LIVING ARRANGEMENTS (continued)

---------

•

11 . Since the date on oage 1 cl'ci anyonE. •ive v ou ; ifts which are not cash?
If "yes." com plete tile follow;11g:

Yes

•

No

-

DESCRIPTION OF
ARTICLE

SOURCE

-----

PHONE
NUMBER

'\JAME/ft.DOI~[ S ([-lumber, Street, City , State, ZIP Code)

MONTHS
RECEIVED

VALUE

..

I

------ ~ - - ----·-··-·- - - -

-

EARNE D INCOME

D

12. Since the date on pa;ie 1, n211e you, o~ your spouse living with y.)u, worked OR do you expect to work in
the next 14 months? If "yes," pleas,?. 9i.-e:

D

No

- - -- - - - - - - - - - - --------'--------

1------ - - - - - ----·
a. Amounts for Past Months

-

EMPLOYE: F·:•s I\IAME, ADDRESS (Number, Street,
c:ty, State ZIP Code) AND PHONE NUMBER

NAME OF WORKER

Yes

GROSS WAGES
Amount

DATES OF
EMPLOYMENT

How Often
Paid

From:

-1---

To:

-

From:
To:

1 - - - - - - - - - - '-

b. Estimates for Current and FuturE· \Aonthr,

Amount $

----!-

- -- - - ·
'

Month
$

Month
- - +- A_m
_ ou_n_t__..._
S_ _ _

$

s

$

$

$

$

$

$

$

$

- - - ----- . $ - - - ·

-1:___

-1!__

•

13. Since the date on page 1 ha 1/€ you, '.)I" yo Jr spo~se living with you, been self-employed or expect to be
self-employed in the ::urrent taxc1bli, :1e::1r? If 'ye,," please give:

--

NAME OF SELFEMPLOYED
PERSON

TYPE OF BUSl1\JESS

--

LAST YEAR'S
THIS YEAR'S ESTIMATED
NET
NET
GROSS
GROSS
INCOME
INCOME
INCOME (OR LOSS)
INCOME
(OR LOSS)

Yes

•

No

DATES OF SELFEMPLOYMENT
From:
To:
From:

_ _..._ _ _ __ ___L _

-- -- - - -· ____ J__

14. If you are disabled, d J yo•.1 h2ve any $peci21I e.xpense, that you paid that are related to your illness or
injury and whicn are necessa ry for }'OU to work~)

To:

•

Yes

•

No

Page 4 of 12

Form SSA-8203-B~C (03-20 18)

UNEARNED INCOME
15. Since the date on page 1. have you, o; your, pause living with you, received , or do you expect to receive in the next 14
months, any of the income ,isled below:
a. Private pensions, anm1;1,es (other tha n Social Security, SSI, or food stamps)?
b . Unemployment or wor~.er''> 1~ompe·1sation?

------

c. TANF or State o r lccal assistanc,~ 'JasecJ

-

e. Rental/lease income?
·-

f. Alimony or child support ' }
g. Dividends or royalties?

- - - - - - - - - - -- ----------

h . Interest earned on rnon ey in bark accounts (including interest on checking accounts)?

---

i. Money from 2 trust Lmd ?

Yes
Yes

D Yes

on nead?

d . Veterans Administ·atio n bene fits (based on need, not based on need, education)?

·--·

•
•

-------j. Money from any otrer pe.-son or 019c1nizati:m?
----·----

•
•
•
•
•
•
•

Yes
Yes
Yes
Yes
Yes
Yes
Yes

•
•
•
•
•
•
•
•
•
•

No
No
No
No
No
No
No
No
No
No

If the answer is ··yes" to an, of thef ~ t;,pe5 oi une;irned income, please give:

RECEI\/EO B~

TYPE OF INCOME

AMOUNT

FREQUENCY

DATES RECEIVED
OR EXPECTED

I

!

SOURCE (Name/Address
of Person, Bank, Company,
or Organization)

From:

I
J_

To:
From:

_

I

__.__ _ _ _ _ _ _ _ L __ _

I

-·---··--

To:

rtt::dOURCES: THINGS YOU OWN

- ~ - - - - - ------------

16. Do you, or your ~i:,ouse livin9 w;t,1 \'vu own a ·ry o'f t11e following items (answer "yes" if your name appears alone or with any
other person as the owner or part cwner of ary of these items):

- - - -- - -- - -- - - - -- - - - . - - - - . - - D Yes
No
- - - - - - - - - - - - - - - - - - - ---------,t-----t--- -

•
• •
• •
• •
- - - - - - - - - - - - - - · - - - - - - - - - - - - - - - - - - - - - - -----,-----i--• •
- - - - - - - - - - - -- - -- - -- -- - - - - - -- - - - - - - - t - - de
• •
- - - - - - - - - - - - - -- --- -- ·---· •·- - - - - - - -- - - - - - - - -- --t--• •
• •
!,.
• •
t - - - - - - - - - - - - - - - ··------ - - - - - -- - -- -- - - - - - - - ---'---- - - a. Cash (with you, at home ir, a sa·'e jeposit bo;<)?

b. Checking accounts·,

Yes

No

c. Saving s accounts?

Yes

No

d. Credit union accou;1ts?

Yes

No

e. Christmas club account::;'?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

f. Savings certificates:certificates ot

cosit'-'

g. Promissory notes or !OU s?

her items that cal'l be ca:;hr,c' o r

i!d?

If "yes," please give the follo1Ving information:

-------~1--------~-- - - - - - - - -- - -- - - - - -

NAME OF EACH ITEM

I,

OWNER(S) OF E/.1.CH ' TOTAL VALUE OF
,,.EM
EACH ITEM

NAME AND ADDRESS OF BANK, COMPANY, OR
ORGANIZATION

- -·--•-·- I
A~¢.LUE

I

I

'
WHEN WAS THE
POLICY PURCHASED

IF THERE IS A LOAN
AGAINST THE POLICY,
GIVE THE AMOUNT

I

I
I

I

19. Is your name, or the name of your spouse living with you, on the title of any vehicles (for example, car,
truck, boat, camper, moiorc:ycie etc )?

··,-- VEA

/•

Yes

•

No

If "yes," please give the followinq infc,rnat1on

NAME OF OVVNcR[S)

R CF
•'EH ICL.E(S)

I

I

MAKE Mm MODEL

CURRENT MARKET
VALUE

HOW MUCH IS
OWED ON
VEHICLE{S)

---I

1-------------'-----

I

MAIN PURPOSE FOR Wf--'ICH T -IE VEHICLE(S) IS USED (For example employment, to obtain medical treatment, etc)

- - - - - - - - - - - - - --·-- - -- -- - - - - - - - -- - - - - -- - -- - - - 1 - - - - - - - - --------- - - - - - · - - - - - - - - - - - - - - -- - - - - - - - - - - +- - - - - - - - - - - - - ---·- - · - -- - - - - - - - - - - - -- - - - -- -,--- -20. Do you, or your spouse living with yoJ, ow!'l or ar= you buying any real estate (land or buildings or other
structures on the land)? (Include prooerty outside the U.S, inherited property, life estates. Do not include
Yes

D

--

D

No

your home.) If "yes," plea ::e Qive th= followi'lg inforrnatic,n:

NAME CF OWNEF<

1--------------

I
~

EST 1MATED
CUl~RErff
111.A RKcT VALUE

AMOUNT OF
TAX ASSESSED MORTGAGE PAYMENT AMOUNT OWED ON
VALUE IF KNOWN
(If any)
THE PROPERTY

- - - - - - - - - 1 - - - - - - - - + - - -- - - - - - + - - -- - - - -

--------------....LI _,_____

-·---+---- - - - - - - + - - - - - -- - - + - - - - - - - -

DESCRIPTION flndude t.\ pe a'1d size of stn,ctures, ccreage
or lot r:;izr: WK. loce-'tio'1 -t pmpe1t~·)

- - - - · - · --

- · --··--·--·

USE (Describe how the property is used. If not in use, give
date of last use and next planned use.)

--- -- --- ----· -- - + - - - - - - - -- - - - - - - - - - - - -

1---- - - - - - -- - - - - - · - ----- --·-----,1---- - - - - -- - - -- - - - - - - - -

I J ' - - - - - - - - - - - - - · - - -- --- - - - - -- ' - - - - - - - - - - - - -- - -- -- - -- _ __

Form SSA-8203-BK (03-2 0 'I 8)

Page 6 of 12
RESOURCES : THINGS YOU OWN (continued)

- - .- - - - - - - - - - - - - - - -

21 . Do you, or your spouse living wifh yau , own any of the following items (answer "yes" if your name or your spouse's name
appears alone or with any otf1er persr.,n 3S the owner or part owner of any of these items.
a. Other household or per.;,onal iter1s n~t already mentioned worth more than $500?
b. Other equipment (business

01

no:ibusine,;s) or property of any kind (not already included on this form?

D
D

D
D

Yes
Yes

No
No

1---- -- - - - - - - - - - - - - - --- - - - - - -- - - - - - - - - - - - - - ~ - - -- - lf "yes," please give the following infor-nati:m:

- - - , - - - -- - - - - - - - - - , - - - - - - - - - - , - - - - - - - - - - OWNER(S) OF EACH ITEM

NAME OF EACH ITEM

1
,

TOTAL VALUE OF
EACH ITEM

HOW MUCH IS OWED
ON EACH ITEM

____J__ _ _ _ _- - + - - - - - - + - - - - 1

1 - - - - - - - - - -- - - - - - - L------------ - - - - + - - - - - - - - - + - - - - - - - - - ---·- ------- _ _j______________- , - - - - ~ - - -- - - ~- - - - - - DESCR IPTION (Where .~p9 ·ooriate, 9-ve name and address
USE (Describe how the property is used. If not in use, give
of bank, company, or c rganization)
date of last use and next planned use.)

---- -- - - -·--

22. a. Do you , or your spousE· livhg with you, own any headstones, or marki~rs, cemetery lots, crypts, urns,
mausoleums, or o·:her rcQL)Sitc:ries f.:,r burial?

r

NAME OF OWNER _ _ _

FOF~ WHOSE BURIAL

-----

RELATIONSHIP TO
YOU OR YOUR
SPOUSE

D Yes D No

DESCRIPTION AND VALUE

-----------+-- -- - -- - - + - - - - - - -- - - -

I

- - - - - - - -- --'---- - - - - - - - ' - - - - - - , - - - -- - - -

b. Do you, or your spous1? living with you, have a,,y money or other assets, such as burial contracts,
trusts, insurance policies, agreerne nts, ·x anything else you intend to use for your burial expenses?
(Include assets listed in items 16-2 1 if Epprc,priate.)

•

Yes

•

No

·--

If "yes," please give the following ink rmation:

------ --- - - ------ ---·· ----·I

DESCRIBE WHAT YOU HAVE SET ,l>.SIDE

--- ·

·-

- - - --- - I

1$ IT IRREVOCABLI=. I
YES

•
•
•

NO

C
Cl

•

-- --- - --

-i

VALUE

I

__ ___J
l
I

· -- · - · - _.J___

NAME OF OWNER

I

-- - ------

] -- --------

~---·- -

---- ----~ -

WHEN DID YOU
SET IT ASIDE
(MM/DD/YYYY)

WILL INTEREST EARNED OR
APPRECIATION IN VALUE
REMAIN IN THE BURIAL FUND
YES

NO

•
•
•

•
•
•

FOR WHOSE BURIAL

Form SSA-8203-13K (0.3-20 18)

Page 7 of 12

23. a . Since the date on page 1, have you, or your spouse living with you, sold, transferred title,
disposed of or give n away any money, or other property, including money or property in

D Yes D

You

No

foreign countries?
Your Spouse D Yes D No
1 - - - -- - - - - · - - --- - -------···-------- - - -- - - - -- - - - + - - - ---+-- - - + -- You
D Yes D No
b . If you co-owned pror,erty with anctl'1er person(s), did you or any co-owner sell, transfer,
or give away any co-owned morey ~r property?

Your Spouse

D

Yes

D

No

If "YES" to (A) or (B), complete the table. If "NO" to both, go to 24.
SOLD ON
OPEN
MARKET

9ooos1I

GIVEN --~RAD":D FOR
AWAY
SEfNICES

!

OWNER'S/CO-OWNER'S NAME(S)

DATE OF DISPOSAL

I

----- ------·-------

II

1 - - - --__J'-------·--·-·--'---------·---- - - - - - - - - - - - - -- -- -~ - - - ' - - - - - - -- f~Afl.l~ /.l.N.J ADDRESS OF PURCHASER OR
DESCRIPTION OF PIWPc:i~-1-Y
RELATIONSHIP TO OWNER
RECIPIENT
l - - - - -- - - - - - - - - - ~---- - - - - - -- - -- - - -- - - -- - - 1 - - - - - - - - - - -- -

1 - - - - - - · -- - - - - - ---- -•-- -- - - - - - - - - · -- - -- - - - - - - - - ! - - - - - - - - -- -

VALUE OF PROPE~TY
0
AND/
or-

c:;~v1g~!~T

r----/

S.!.\!J:: PRICE OR OTHER
ccr,Js iDEJ<~,TION REC EIVED

ARE ADDITIONAL CONSIDERATION OR PROCEEDS
EXPECTED? EXPLAIN

f - - - - - - - -- - - - - - - i'- - -- ---------·- --- - - - ---1--- - - - - - -- - - - --

-----

1---------t-------------+---- .- DO YOU STILL OWN
THE PROPERTY?
YES

•
•

I

NO

I

[~

1

I
i

I

1------....L.- - -------- --- '7
L~

i

IF '{ ES, EXPLAIN

..... ---------------- - - - - - - - - - -- - - - -- - -- --

---+-- - - - - ' -- - -- - - - - -..--,------ - -- - - -- -- - - - - - - --

- - - -. -- - - - -

24. Since the date on page 1 have you (o~ your spot..se living with you) had any change in health insurance
coverage or other insurance that pays for medical bills? (Do not include Medicare , but do include
/insurance such as accident, autom,:ibire, or cas Jalty if ii covers medical bills for any reason.)

IF YOU LIVE ,N CALIFORNIA, PLEASE DO NOT A NSWER QUESTION 25 BELOW.

D

Yes

D

No

Form SSA-8 203-BK (03-2018)

Page 8 of 12

--------·

25.

You

•
•
•
•
•
•

a. Are you current111receiving food stamps?
If YES go to "b." If NO, go to "c."
b. Have you received 2 recertification ,. 1otice within the past 30 days?
If YES , go to "e." If IKl, go to question 26.

··---- ----

c. Have you filed for food stamps in the last 60 days?
If YES, go to "d. " If NO, go to "e."
d. Have you received a favorable de~:i$ior,?
If YES, go to quest;o,1 26. If NO, go to "e."

----

e . Is everyone i1; the household app'ying for or re,~eiving SSI?
If YES, go to 'f." If NO, gc to quEsfo1 26.
f. May I take your food starn~, appliGa tion today?
If YES, go to question 2•3. If NO, e:e ~uei,ticns un'2ss we display a valid Office of Management and Budget (0MB)
control number. We estimcitc: that ,t v1ill t,;,:e ab:>c1t 20 minutes to read the instructions, gather the facts, and answer the
questions. Send only cornments refatinr,r i'.i, our tinu~estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Form SSA-8203-BK (03-20'.8)

Page 11 of 12
F~Epc,rting Responsibilities

• The amount of your 8SI check n based ,y1 the information you tell us. To continue getting the right payment amount, you must
report certain changes tl'lat happen to yo.; Changes could make your check bigger or smaller.
• You must tell us about change,; wit:, in 10 days afte,· the month they happen. If you do not report changes, we may have to take
as much as $25, $50, or $100 out of futum checlu receive.
• You must also report changes :n incon-.e for yo_1r ineligible spouse or ch ildren who live with you, or your sponsor or sponsor's
spouse if you a ·e an alien. You ·nust cilso 'eport if a11y of these people buy or sell anything of value.
• A List of Most of the Changes You Mw;, Rep;:irt Is Ori The Next Page.

How To Report Changes
You can report changes in any rA the foliov11ng ways:
• Call us, toll free , at 1-800-?n-121~
• Call your local Social Security rJftice 2t the numl:-er at the ·op of this form.
• By mail or in pe,rson - see the adaress at the top 01' t<1is form
Important Facts About Food Stamps
• You can apply for food stamps 31 l he S::.c,al Se:::urity Office if you and everyone in your household get or apply for SSI
• The Socia' Security O'f1ce will !1elp you i'il, out ·:1·1c food stamp application . You do not have to go to the food stamp office
to apply.

Page 12 of 12

Form SSA-8203-BK (03-2018)

CHANGES TO REPORT

D

D

WHERE YOU LIVE - You must report to Social Security if:
• You move.

• You leave the United States for 30 days or more.

• You (or your spouse leave your household for a calendar
month or longer. For example, you enter a hospital or visit
a relative.

• You are released from a hospital, nursing home, etc.
• You are no longer a legal resident of the United States.

HOW YOU LIVE - You mus': report to Social Security:
• If someone moves into or out of your hous,:hold.
• If the amount of money you pay toward household
expenses changes.

• Changes in your marital status:

• If your former .,;pouse di-es.

• You get married, separated, divorced, or your marriage
is annulled.
• You separate from you r spouse or start living together
again after a separation.

• Births anc! deaths cf any people with wh:-:im you live.

• You begin living with someone as husband and wife .
• Your spouse dies.

D

•

INCOME - You mu3t report to Social :3ecurity if:
• The amoun~ of mo·1ey (or che ~k~; er my other type ol'
payment) you receive fro111 someoIIe or someplace goes
up or down or you sta1t 1c re ::eive rnone/ ( or checks or
any other type o-f payrv1ent).

o; payrnrnt of household

expenses) you receive goes '..Ip er c: own.

•

• Your earnings go up or down.
• You become eligible for benefits other than SSI.

HELP YOU GET FROM OTHERS - Y:iu rnu~t repoIi to Social Security if:
• The amount of help (rr.oriey, food

•

• You start work or stop work.

• Someone stops helping you.
• Someone starts helping you.

THINGS OF VALUE TH,\T YOU CWI,' - You must report to Social Security if:
• The value of your resources 9oes over ~;2,000 when you
add them all :ogether ($3.':::t.1 if '.'O .1 ,ar,:: inaI r!t: :1 cmd live
with your spouse).

• You sell or give any things of value away.
• You buy or are given anything of va lue.

- - ------·------------------·-- - - - - - - -- - - - - -- - -- - - - - - - -- -- - - - -

•
•
•

YOU ARE BLIND OR Di~ABLED · Ycu must report to Social Security if:
• Your condition improves or your doctor says you can
return to work

• You go to work.

YOU ARE UNMARHIED ~ND UN,JER A.Ge 22 - A report to Social Security must be made if:
• You are under age rn and live w ith your parent(s), ask
your parents to re;ioi if they have a ::hange i1 income, a
,::hange in their mar·lage, ;:, ~nanrp in the val•Je of
anything they ow11 er either has a c~Iange in re.sidence.

• There are changes in the income, school attendance (if
between the ages of 18 and 21 }, or marital status of
ineligible children who live in your household.

• You get marred.

• You start or stop school.

- - -- - - - -- - - - - · - - · YOUR IMMIGRATION /.1\'.J NATURALIZ.A.TION SERVICE (INS) STATUS CHANGES - You must report any changes to
Social Security.
YOU ARE A REPRESENTATIVE 0 ,A,YEE · You must report to Social Security if:
• The person fo,· w hom yet. 1eceiv~ :;S/ checks I· as any of the changes listed above. (You may be held liable if you do not
report changes tha'. could affect t'1e S~ I re:::ipient's payment amount, and he/she is overpaid.)
• You will no longe-r be a ,)1£! or no

i,:,r,; :r ,visit to act as the person's representative payee.