Form SSA-624-F5 Representative Payee Evaluation Report

Form Approved
OMB No. 0960-0069

SOCIAL SECURITY ADMINISTRATION

REPRESENTATIVE PAYEE EVALUATION REPORT

TP

CC

TYA

GS

NAM

MBA

BENEFICIARY'S NAME

CF
SOCIAL SECURITY NUMBER

REPORT PERIOD

PAYEE'S NAME

From:
PAYEE'S ADDRESS

To:
ZIP CODE

CITY AND STATE

PART I
1.

INFORMATION FROM PAYEE

GUARDIANSHIP STATUS

YES

Is legal guardianship now in effect?

NO

If yes, show guardian's name and address below (if other than payee).

GUARDIAN'S NAME

2.

PHONE NUMBER (Include area code)

GUARDIAN'S ADDRESS

CUSTODY

YES

(a) Did the beneficiary live alone or with someone other than the payee?

NO

If yes, answer 2(b). If no, skip to item 4.

(b) Show below where the beneficiary lived. Show the relationship of the custodian to the beneficiary, the dates of residence and the reason for
any change in custody.

NAME

3.

ADDRESS

RELATIONSHP

DATES OF
RESIDENCE

REASON FOR
CHANGE

DEMONSTRATION OF CONCERN
(a) How did the payee learn of the beneficiary's needs?

(b) Did the payee maintain contact with the beneficiary? If yes, show type of
contact (visits, phone, letters) and frequency. If no, explain.

(c) Did the payee provide the beneficiary with funds for personal spending?
If yes, show to whom the funds were given (e.g., directly to the beneficiary,
the custodian). If no, show why not.

4.

YES

NO

YES

NO

YES

NO

USE OF BENEFITS
(a) Did the payee turn over the checks or the full amount of the checks to another
party?
If yes, show to whom the funds were given (e.g., the beneficiary, the
NAME
custodian).
AMOUNT $
(b) Amount used for beneficiary's care and maintenance. If paid to another party,
show to whom.
NAME

Form SSA-624-F5 (09-2013) ef (09-2013)
Use (09-2004) ef (10-2010) edition until exhausted

PART I (continued)

4. (cont.)

AMOUNT

(c) Amount used for beneficiary's clothing.

$

(d) Amount used for beneficiary's personal expenditures. If less than $360, explain in remarks.
(e) Amount used for other than items (b) through (d) above. (Exclude savings.)
Explain in remarks.

AMOUNT
$
AMOUNT
$
TOTAL AMOUNT

(f) Total amount of benefits used.

$

(g) Did the payee record expenditures (receipts, cancelled checks, etc.)?

5.

YES

NO

CONSERVED FUNDS
(a) Total amount of conserved funds.
Subtract item 4(f) from TYA and add conserved funds from prior years.

AMOUNT
$
Enter an amount or zero
in the above field

(b) How are conserved funds held?

CASH

U.S. SAVINGS BONDS

CHECKING ACCOUNT

SAVINGS ACCOUNT

OTHER (Explain)

(c) HOW ARE CONSERVED FUNDS TITLED?

TYPE OF
HOLDING

TITLE OR
OWNERSHIP

ACCOUNT
NUMBER

(e) Are funds clearly recorded as belonging to the beneficiary?

(d) Are the funds mingled with funds of another person(s)?

YES

NAME AND ADDRESS
OF BANK

NO

YES

NO

YES

NO

If yes, answer (e).

6.

OTHER INCOME
(a) Did the beneficiary have other income which affects the entitlement
to or use of Social Security benefits?
(b) Type Of Other Income

WORKMEN'S COMPENSATION

VA BENEFITS

OTHER (Explain)

PUBLIC ASSISTANCE (Explain)
YES

(c) Is there a payee for other income?

ADDRESS OF PAYEE

OTHER INFORMATION

YES

Has the payee ever been convicted of a crime considered to
be a felony?

8.

NO

If yes, show name and address of payee below.

NAME OF PAYEE

7.

If yes, answer (b) and (c).

NO

If yes, explain in remarks .

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.

DATE

SIGNATURE

Form SSA-624-F5 (09-2013) ef (09-2013)

Page 2

PART II
1.

INFORMATION FROM BENEFICIARY

ALL CUSTODY SITUATIONS
(a) Is the beneficiary aware of entitlement to Social Security benefits?

YES

(b) Did the beneficiary participate in decisions on expenditures?

NO

YES

(c) Did the beneficiary receive funds for personal spending?

YES

(d) Were any large purchases made for the beneficiary?

NO

YES

NO

EXPLANATION

(e) Does the beneficiary have any unmet needs?

YES

NO

NO

If yes, explain.
(f) Did the beneficiary live with someone other than the payee?

YES

(g) Did the beneficiary live alone?

NO

YES

If yes, answer 2. below.

2.

NO

If yes, answer 2. and 3. below.

BENEFICIARY NOT IN PAYEE'S CUSTODY
(a) Did the payee maintain contact with the beneficiary?

YES
If yes, show type of contact
(visit, phone, letters) and frequency.

NO
If no, explain

(b) Did anyone other than the payee demonstrate concern for the
beneficiary?

YES

NO

If yes, show who and type and frequency of contacts.

3.

BENEFICIARY LIVED ALONE
(a) Was the beneficiary responsible for his/her maintenance expenses?
(Rent, utilities)

YES
4.

NO

YES

NO

YES

NO

OTHER INFORMATION
Have any suspension or termination events occurred (e.g., marriage of
child beneficiary)?

5.

(b) Did the beneficiary purchase his/her food and clothing?

REMARKS

Form SSA-624-F5 (09-2013) ef (09-2013)

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(If yes, explain in remarks)

PART III INFORMATION FROM CUSTODIAN
CUSTODIAN'S NAME

1.

ADDRESS

PHONE (Include area code)

PAYEE AND CUSTODIAN ARE NOT THE SAME PERSON OR ORGANIZATION

YES

(a) Did the beneficiary live with the custodian during the
entire report period?

NO

If no, show other
custodians if known.

(b) Who would the custodian notify in cases of emergency?

(c) Was a charge made for care and maintenance of the beneficiary?
If yes, show the amount paid by the payee.

NO

YES

NO

Amount $

(d) Did the payee demonstrate personal concern for the beneficiary?
FREQUENCY OF VISITS

YES

If yes, explain below .

PROVIDES CLOTHING

YES

GIFTS

NO

YES

(e) Did the payee contribute money for the beneficiary's personal use?
If yes, show the amount contributed by the payee.

OTHER (Specify)

NO

YES

NO

YES

NO

Amount $
(f) Does the custodian hold and control the beneficiary's
personal use funds?

If yes, answer (g).

(g) Are the beneficiary's funds mingled with funds of other persons?

YES
2.

NO

YES

NO

ALL CUSTODIANS
Were any group purchases made?

YES
3.

If yes, are the funds clearly designated as the beneficiary's?

If yes, were the purchases approved by SSA?

NO

YES

NO

REMARKS

PART IV

SIGNATURE AND TITLE

Form SSA-624-F5 (09-2013) ef (09-2013)

EVALUATION AND ACTION TAKEN

OFFICE

Page 4

DATE

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(j)(3) and 1631(a)(2)(c) of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to determine your suitability to continue being a
representative payee and to determine if the beneficiary's current needs are being met.

See Revised Privacy Act Statement Attached

Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may
cause us to terminate you as a representative payee.
We rarely use the information you supply us for any purpose other than to make a determination regarding
your suitability as representative payee and the beneficiary's current needs. We may disclose information to
another person or to another agency in accordance with approved routine uses, which include but are not
limited to the following:
1. To enable a third party or agency to assist us in establishing rights to Social Security benefits
and/or coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under
contract with us).
We also may use the information you give us in computer matching programs. Matching programs compare
our records with records kept by other Federal, State and local government agencies. We use the information
from these programs to establish or verify a person's eligibility for federally funded or administered benefit
programs and for repayment of incorrect payments or delinquent debts under these programs.
A complete list of routine uses of the information you provided us is available in our Systems of Records
Notices entitled, Claims Folder System, 60-0089 and Master Representative Payee File, 60-0222. These
notices, additional information regarding this form, and information regarding our programs and systems, are
available online at www.socialsecurity.gov or at your local Social Security office.

See Revised PRA Statement Attached
Paperwork Reduction Act 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 30 minutes to read the instructions, gather the facts, and answer the questions related to
representative payment. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may
call Social Security at 1,800,772,1213 (TTY 1,800,325,0778). You may send comments on our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.

Form SSA-624-F5 (09-2013) ef (09-2013)

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