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The SSA-11 form is a request for individuals to be designated as representative payees for Social Security benefits. This form allows someone to manage benefits on behalf of a claimant who is unable to do so themselves. Completing the SSA-11 is essential for ensuring that the claimant's needs are met appropriately.

Outline

The SSA-11 form, also known as the Request to be Selected as Payee, is an important document for those who wish to manage Social Security benefits on behalf of someone else. This form is primarily used when an individual, referred to as the "claimant," cannot handle their own benefits due to various reasons, such as age or disability. The form requires the applicant to provide personal information about both themselves and the claimant, including Social Security numbers and living arrangements. It also asks for details on why the claimant is unable to manage their benefits and how the applicant plans to meet the claimant's needs. Furthermore, the SSA-11 includes questions regarding any legal guardianship and the applicant's relationship to the claimant. Understanding how to fill out this form accurately is crucial, as it ensures that benefits are directed to the right person and used for the claimant's needs. This article will delve into the key aspects of the SSA-11 form, guiding you through the application process and highlighting essential considerations for prospective payees.

Form SSA-11-BK (09-2020) UF
Discontinue Prior Editions							Page 1 of 11
Social Security Administration							OMB No. 0960-0014
			FOR SSA USE ONLY				FOR SSA USE ONLY

	Name or	Program	Date of	Type Gdn. Cus.	Inst. Nam.
Request to be	Bene. Sym.	Program	Birth	Type Gdn. Cus.	Inst. Nam.
Request to be
Selected as
Payee
Payee
							District Office Code
							District Office Code

Print in Ink							State and County Code
							State and County Code

The name of the NUMBER HOLDER						SOCIAL SECURITY NUMBER

The name of the PERSON(S) (if different from above) for whom you are filing (the						SOCIAL SECURITY NUMBER (S)
"claimant(s)")

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

1.I request that I be paid directly

CHECK HERE and answer only items 3, 5, 6, and 8 before signing the form on page 5.

I REQUEST THAT THE SOCIAL SECURITY, SUPPLEMENTAL SECURITY INCOME, OR SPECIAL VETERANS BENEFITS FOR THE CLAIMANT(S) NAMED ABOVE BE PAID TO ME AS REPRESENTATIVE PAYEE.

2.Explain why you think the claimant is not able to handle his/her own benefits. (In your answer, describe how he/she manages any money he she receives now.)

Claimant is a minor child

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

4.If you are appointed payee, how will you know about the claimant's needs?

Live with me or in the institution I represent
Daily visits
Visits at least once a week.
By other means. Explain:

5. Does the claimant have a court-appointed legal guardian/conservator?	Yes	No
If Yes, enter the legal guardian/conservator'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 (09-2020) UF		Page 2 of 11
6. (a) Where does the claimant live?
	Alone
	In my home (Go to (b).)	In a public institution (Go to (c).)
	With a relative (Go to (b).)	In a private institution (Go to (c).)
	With someone else (Go to (b).)	In a nursing home (Go to (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 any other people who live with the claimant.

	NAME	RELATIONSHIP

Residence:	Mailing:	Telephone
		Number

(d) Do you expect the claimant's living arrangements to change in the next year?

Yes

If Yes, explain what changes are expected and when they will occur. (Use Remarks if you need more space.)


7. If you are applying on behalf of minor child(ren) and you are not the parent,
Is the child(ren) in foster care?	Yes	No
Does the child(ren) have a living natural or adoptive parent?	Yes	No
If yes, enter: (a) Name of parent
(b) Address of parent
(c) Telephone number
(d) Does the parent show interest in the child?	Yes	No
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	ADDRESS/PHONE NO.	RELATIONSHIP	DESCRIBE

Form SSA-11-BK (09-2020) UF

Page 3 of 11

9.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	State, county, or local government agency	Social Agency	Public Official
Institution:
Federal	State/Local	Private non-profit
Private proprietary institution. Is the institution licensed under State law?			Yes	No

IF (a) ABOVE CHECKED, COMPLETE ONLY QUESTIONS 10 AND 11 AND SIGN THE FORM ON PAGE 5.

(b) Parent

(d) Other Relative - Specify

(e) Legal Representative

(f) Board and Care Home Operator

(g) Other Individual - Specify

IF (b), (c), (d), or (e) ABOVE CHECKED, GO ON TO QUESTION 12

10. Does the claimant owe you/your organization any money now or will he/she owe you money in the future? Yes No

If Yes, enter the amount he/she owes you/your organization, the date(s) was/will be incurred and describe why the debt was/ will be incurred.

INFORMATION ABOUT INSTITUTIONS, AGENCIES, AND BANKS APPLYING TO BE REPRESENTATIVE PAYEE

11.(a) Enter the name of the institution

(b) Enter the EIN of the institution

13.How long have you known the claimant?

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

15.(a) Main source of your income

Employed (answer (b) below)
Self-employed (Type of Business								)
Social Security benefits (Claim Number								)
Pension (describe								)
Supplemental Security Income payments (Claim Number								)
Temporary Assistance For Needy Families (TANF								)
Other State or Public Assistance (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.)

Form SSA-11-BK (09-2020) UF

Page 4 of 11

16.

Do you give Social Security permission to conduct a criminal background check on you?

Yes

17.

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

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 did/will your probation end?

(b) Have you ever been convicted of any offense under federal or state law which resulted in imprisonment

Yes

for more than one year?

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 did/will your probation end?

18.

Do you have any unsatisfied FELONY warrants (or in jurisdictions that do not define crimes as felonies, a crime punishable

by death or imprisonment exceeding 1 year) for your arrest?

Yes

If Yes: Date of Warrant

State where warrant was issued

19.

How long have you lived at your current address? (Give Date MM/YY)

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

Form SSA-11-BK (09-2020) UF	Page 5 of 11
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING THIS FORM

I/my organization:

•Must use all payments made to me/my organization as the representative payee for the claimant's current needs or (if not currently needed) save them for his/her future needs.

•May be held liable for repayment if I/my organization misuse the payments or if I/my organization am/is at fault for any overpayment of benefits.

•May be punished under Federal law by fine, imprisonment or both if I/my organization am/is found guilty of misuse of Social Security or SSI benefits.

I/my 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 to misuse of Social Security or SSI funds by me/my organization.

•Notify the Social Security Administration when the claimant dies, leaves my/my organization's custody or otherwise changes his/her living arrangements or he/she is no longer my/my organization's responsibility.

•Comply with the conditions for reporting certain events (listed on the attached sheets(s) which I/my organization will keep for my/my 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 I/my organization can no longer act as representative payee or the claimant no longer needs a payee.

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.

SIGNATURE OF APPLICANT

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

DATE (MM/DD/YYYY)

Telephone number(s) at which you may be contacted during the day

Print Your Name & Title (if a representative or employee of an institution/organization)

Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)

City and State

ZIP Code

Name of County

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

City and State

ZIP Code

Name of County

Witnesses are only required if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the signing who know the applicant making the request must sign 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 (09-2020) UF

Page 6 of 11

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 divorced wife/husband, 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 benefit's;

•the claimant leaves your custody or care or otherwise CHANGES ADDRESS;

•the claimant NO LONGER HAS A CHILD IN CARE, if he/she 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) issue for his/her 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 CLAIMAINT 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 a 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 to 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 of any payments not used for the claimant's needs or of any over payment 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 correct accounting;

•to tell us as soon as you know you will no longer be able to 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 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-11-BK (09-2020) UF				Page 7 of 11
		A REMINDER TO PAYEE APPLICANTS

Telephone	Before you Receive a		SSA Office	Date Request
Telephone	Decision Notice			Received
Number(s) to Call	Decision Notice			Received
if you have a
Question or	After you Receive a
Something to	Decision Notice
Report	Decision Notice
Report

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

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

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

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

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

BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER

Privacy Act Statement

Collection and Use of Personal Information

Sections 205(a), 205(j), and 1631(a) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on your request for selection as a representative payee.

We will use the information to determine your eligibility to serve as a representative payee. We may also share your information for the following purposes, called routine uses:

•To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA) in the efficient administration of its programs;

•To agencies or entities who have a written agreement with SSA, to perform reviews of the representative payee program and to provide training, administrative oversight, technical assistance, and other support for the program review; and

•To third parties, contractors, or other Federal agencies, as necessary, to conduct criminal background checks and to obtain criminal history information on representative payees and representative payee applicants.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089 entitled Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784; 60-0222, entitled Master Representative Payee File, as published in the FR on November 2, 2018, at 83 FR 55228; and 60-0320, entitled Electronic Disability Claim File, as published in the FR on December 22, 2003, at 68 FR 71210. Additional information, and a full listing of all our SORNs, is available on our website at www.ssa.gov/privacy.

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 (OMB) control number. We estimate that it will take about 11 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Form SSA-11-BK (09-2020) UF

Page 8 of 11

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 in/out of the place where the claimant lives);

•the claimant LEAVES THE U.S. (the 50 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 he/she 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 his/her 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 his/her arrest;

•the claimant is violating a condition of probation or parole under State or Federal law.

IF THE CLAIMANT IS RECEIVING PAYMENTS DUE TO DISABILITY 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 to 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 to 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;

•to 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 to keep evidence to help us with the redetermination (e.g., evidence of income and living arrangements).

•you may be required to obtain medical treatment for the claimant's disabling condition if he/she 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-11-BK (09-2020) UF				Page 9 of 11
		A REMINDER TO PAYEE APPLICANTS

Telephone	Before you Receive a		SSA Office	Date Request
Telephone	Decision Notice			Received
Number(s) to Call	Decision Notice			Received
if you have a
Question or	After you Receive a
Something to	Decision Notice
Report	Decision Notice
Report

			RECEIPT FOR YOUR REQUEST

Your request for SSI payments on behalf of the individual(s) named below has been received and will be processed as quickly as possible.

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

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

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

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

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

BENEFICIARY

SOCIAL SECURITY CLAIM NUMBER

Privacy Act Statement

Collection and Use of Personal Information

We will use the information to determine your eligibility to serve as a representative payee. We may also share your information for the following purposes, called routine uses:

•To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA) in the efficient administration of its programs;

Paperwork Reduction Act Statement

Form SSA-11-BK (09-2020) UF

Page 10 of 11

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 he/she 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 his/her arrest;

•the claimant is violating a condition of probation or parole under State or Federal law.

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 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.

REMEMBER:

•payments must be used for the claimant's current needs or saved if not currently needed;

•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;

•to let us know, as soon as you know you are unable to continue as representative payee or the claimant no longer needs a payee.

Click for PDF

Fact Name	Description
Purpose of SSA-11	The SSA-11 form is used to request to be appointed as a representative payee for someone who is unable to manage their Social Security benefits.
Eligibility Criteria	Individuals applying to be a payee must demonstrate that the claimant cannot handle their own benefits, often due to age or disability.
Required Information	The form requires details about the claimant, including their living situation and any legal guardianship arrangements.
Signature Requirement	Applicants must sign the form in ink, confirming that the information provided is accurate to the best of their knowledge.
Witnesses	If the applicant signs by mark (X), two witnesses must sign the form, providing their addresses as well.
Legal Obligations	Payees must use benefits for the claimant's current needs and may be liable for repayment if funds are misused.
Reporting Changes	Payees are required to notify the Social Security Administration of any significant changes in the claimant's circumstances, such as death or change of address.
Background Check	Applicants must consent to a criminal background check, which is part of the vetting process for potential payees.
State-Specific Forms	Some states may have additional requirements or forms that must be submitted alongside the SSA-11, governed by local laws.
Form Updates	The SSA-11 form is periodically updated, and older editions should be destroyed to avoid confusion.

Filling out the SSA-11 form is an important step in the process of requesting to be a representative payee for someone who cannot manage their own benefits. After completing the form, it will need to be submitted to the Social Security Administration for review. Ensure that all information is accurate and complete to avoid delays.

Begin by printing your information clearly in ink at the top of the form. Include your name, Social Security number, and the name of the claimant.
Indicate if you want the benefits to be paid directly to you by checking the appropriate box.
Provide an explanation of why the claimant cannot handle their own benefits, detailing their current money management.
Describe why you believe you would be the best representative payee. Use the Remarks section if you need more space.
State how you will stay informed about the claimant's needs, selecting from the options provided.
Answer whether the claimant has a court-appointed guardian or conservator, and if so, provide their details.
Specify where the claimant lives and provide the names and relationships of anyone else living with them.
If applying for a minor child, answer questions regarding the child's parents and their involvement.
List any relatives or friends who support the claimant, along with details about the support provided.
Check the box that describes your relationship to the claimant and answer the corresponding questions.
Indicate if the claimant owes you or your organization any money and provide details if applicable.
Fill out your personal information, including your name, date of birth, and Social Security number.
Answer questions regarding your relationship with the claimant and your income sources.
Indicate whether you consent to a background check and answer questions about any felony convictions.
Sign the form in ink, providing the date and your contact information.
If necessary, have two witnesses sign the form, providing their addresses.

What is Form SSA-11?
Form SSA-11 is a request to be selected as a representative payee for someone receiving Social Security benefits. This form is used when an individual believes that a claimant is unable to manage their own benefits due to various reasons, such as age or disability.
Who can fill out Form SSA-11?
The form can be filled out by anyone who wishes to act as a representative payee for a claimant. This includes parents, guardians, or individuals from institutions responsible for the claimant’s care. It is important that the person filling out the form has a genuine interest in the claimant's well-being.
What information is required on the form?
The form requires various details, including:
- The name and Social Security number of the claimant.
- The relationship of the payee to the claimant.
- Information about the claimant's living situation.
- Details about the payee’s income and background.
Why would someone need a representative payee?
A representative payee is needed when a claimant cannot manage their benefits due to reasons like mental incapacity, severe physical limitations, or being a minor. The payee ensures that benefits are used for the claimant's current needs and future expenses.
How does one become a representative payee?
To become a representative payee, an individual must complete Form SSA-11 and provide necessary information about their relationship to the claimant. The Social Security Administration will review the application and determine if the individual is suitable for the role.
What responsibilities does a representative payee have?
A representative payee is responsible for using the benefits to meet the claimant's needs, keeping accurate records of how the funds are spent, and reporting any changes in circumstances to the Social Security Administration. Misuse of funds can lead to serious legal consequences.
Can a representative payee be changed?
Yes, a representative payee can be changed if it is determined that the current payee is no longer suitable or if the claimant's needs change. The new payee must submit a new Form SSA-11 for approval.
What happens if the claimant dies?
If the claimant dies, the representative payee must notify the Social Security Administration immediately. Benefits will stop for the month prior to the claimant’s death, and any unspent funds must be returned.
Where can I get Form SSA-11?
Form SSA-11 can be obtained online from the Social Security Administration's website or by visiting a local Social Security office. It is important to ensure that you are using the most current version of the form.

Filling out the SSA-11 form can be a straightforward process, but many people make common mistakes that can delay their application. One frequent error is failing to provide complete and accurate information. When applicants leave sections blank or provide vague answers, it can lead to confusion and additional requests for clarification from the Social Security Administration (SSA). Each question is designed to gather specific information, and incomplete responses can hinder the review process.

Another mistake is not clearly explaining the claimant's inability to manage their own benefits. The form asks for detailed explanations, yet some applicants provide minimal information. It is essential to describe the claimant's current financial situation and how they handle any money they receive. A thorough explanation helps the SSA understand why a representative payee is necessary.

Additionally, many applicants overlook the importance of providing accurate contact information. Failing to include a current phone number or mailing address can lead to missed communications from the SSA. If the SSA cannot reach the applicant for follow-up questions, it may result in delays or even denials of the application.

Some individuals also forget to check the appropriate boxes that indicate their relationship to the claimant. This oversight can create confusion about the applicant's role and responsibilities. It's important to ensure that the correct relationship is documented, as this helps establish the legitimacy of the payee's request.

Another common error involves not notifying the SSA of any changes in circumstances. If there are changes in the claimant's living situation or financial needs, these must be reported promptly. Failing to do so can lead to complications or even potential overpayments that the payee may be held responsible for repaying.

Moreover, applicants sometimes fail to sign and date the form correctly. An unsigned or improperly dated form will be rejected, causing unnecessary delays. It is crucial to double-check that all required signatures are present before submitting the application.

Lastly, some applicants neglect to read the instructions carefully. The SSA provides specific guidelines on how to fill out the form, and overlooking these can result in mistakes. Taking the time to review the instructions can help ensure that the application is completed correctly and submitted without issues.

The SSA-11 form, officially known as the Request to Be Selected as Payee, is utilized by individuals seeking to become representative payees for Social Security benefits. In conjunction with this form, several other documents may be necessary to ensure a complete application process. Below is a list of related forms and documents commonly required alongside the SSA-11 form.

SSA-16: This form is used to apply for Social Security Disability Insurance (SSDI) benefits. It collects information about the applicant's work history, medical conditions, and other relevant details necessary for determining eligibility.
SSA-827: This is a medical release form that authorizes the Social Security Administration (SSA) to obtain medical records from healthcare providers. It is essential for verifying the claimant's medical condition.
SSA-3368: Known as the Disability Report, this form gathers detailed information about the claimant's work history, education, and medical conditions. It is crucial for assessing the severity of the disability.
SSA-3373: This form, titled Function Report, asks about the claimant's daily activities, social interactions, and limitations due to their medical condition. This information aids in evaluating the impact of the disability on daily life.
Form 4506-T: This document is used to request a transcript of tax returns from the IRS. It may be necessary to verify income information for the claimant or their representative payee.
Form SSA-11-BK: This is the detailed version of the SSA-11 form, which includes more comprehensive questions about the claimant's circumstances and the proposed payee's qualifications.
SSA-3820: This form, also known as the Representative Payee Report, is used by payees to report how benefits have been spent on behalf of the claimant. It is required annually to ensure compliance with SSA regulations.
Form SSA-827: This form is a medical release that allows the SSA to gather necessary medical information from healthcare providers to support the claim for benefits.
Proof of Identity: This document, which may include a driver's license or passport, is required to verify the identity of the representative payee and the claimant.
Proof of Relationship: Documents such as birth certificates or marriage licenses may be needed to establish the relationship between the claimant and the proposed payee.

Each of these forms and documents plays a critical role in the application process for Social Security benefits. They help ensure that the SSA has all necessary information to make informed decisions regarding eligibility and the appropriate allocation of benefits. Proper completion and submission of these documents can facilitate a smoother application experience for both claimants and their representative payees.

The SSA-11 form is a request to be selected as a representative payee for Social Security benefits. Several other documents serve similar purposes in different contexts. Here are nine documents that share similarities with the SSA-11 form:

Form SSA-16: This form is used to apply for Social Security Disability Insurance (SSDI) benefits. Like the SSA-11, it requires detailed information about the applicant's situation and ability to manage finances.
Form SSA-827: This form is an authorization for the Social Security Administration to obtain medical records. It parallels the SSA-11 in its focus on the claimant’s needs and circumstances.
Form SSA-3373: This form is used to collect information about the claimant's daily activities and functional abilities. It serves a similar purpose in assessing the claimant's ability to manage their benefits.
Form SSA-1101: This form is for disability applicants to provide information about their work history. It complements the SSA-11 by detailing how the claimant's work impacts their ability to manage finances.
Form SSA-44: This form is used to request a reduction in the amount of benefits due to a change in income. It shares the need for financial transparency found in the SSA-11.
Form SSA-154: This is a request for reconsideration of a denied claim. Similar to the SSA-11, it involves providing detailed information to support the claimant's case.
Form SSA-21: This form is used to report a change in income or resources. It aligns with the SSA-11's focus on the claimant's financial situation and needs.
Form SSA-827 (Revised): This updated version of the SSA-827 includes additional questions to clarify the claimant's medical and financial status, similar to the SSA-11's inquiries.
Form SSA-8: This form is used to apply for a lump-sum death benefit. It requires information about the deceased’s financial circumstances, akin to the details requested in the SSA-11.

Each of these forms plays a critical role in managing Social Security benefits and ensuring that the needs of claimants are adequately addressed.

When filling out the SSA-11 form, it's important to approach the process with care. Here are five things you should and shouldn't do to ensure your application is handled smoothly:

Do read the instructions carefully before starting. Understanding what each section requires can save you time and avoid mistakes.
Don't leave any required fields blank. Incomplete forms can lead to delays or rejections.
Do provide clear and honest answers. Transparency helps the Social Security Administration assess your application accurately.
Don't use pencil or erasable ink. Always fill out the form in black or blue ink to ensure legibility.
Do keep a copy of the completed form for your records. This can be useful if you need to reference it later.

By following these guidelines, you can help ensure that your application process goes as smoothly as possible.

Understanding the SSA-11 form, which is used to request to be selected as a representative payee for Social Security benefits, can be challenging. Here are eight common misconceptions about this form:

Only family members can be representative payees. While family members often serve in this role, anyone who meets the criteria can apply. This includes friends, caregivers, and professionals from organizations.
The SSA-11 form is only for minors. This form can be used for any claimant who is unable to manage their benefits, including adults with disabilities.
Once appointed, a payee can use the funds for any purpose. Representative payees must use the funds solely for the claimant's current needs or save them for future needs. Misuse can lead to legal consequences.
There is no need to report changes in the claimant's situation. Payees are required to report significant changes, such as the claimant’s death or changes in living arrangements, to the Social Security Administration promptly.
The SSA-11 form guarantees appointment as a payee. Completing the form does not guarantee approval. The Social Security Administration will review the application and determine eligibility based on various factors.
Payees do not have to provide any accounting for the funds. Payees must keep records of how the benefits are spent and may be required to submit an accounting report to the SSA.
Anyone can apply to be a payee without a background check. The SSA conducts background checks on applicants, particularly regarding any felony convictions or unsatisfied warrants.
Once appointed, the payee’s role is permanent. The appointment can be revoked if the SSA determines that the payee is not acting in the best interest of the claimant or if the claimant no longer requires a payee.

By clarifying these misconceptions, individuals can better understand the responsibilities and requirements associated with the SSA-11 form and the role of a representative payee.

INFORMATION ABOUT INDIVIDUALS APPLYING TO 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

The SSA-11 form is used to request to be appointed as a representative payee for someone who is unable to manage their own Social Security benefits.
It is essential to provide accurate information about both the claimant and the payee. This includes names, Social Security numbers, and addresses.
Only fill out item 1 if you are the claimant requesting direct payment. If you are applying as a representative payee, skip to item 2.
Clearly explain why the claimant cannot handle their own benefits. This explanation should include details about how they manage any money they currently receive.
It is important to describe why you would be the best representative payee. Your qualifications and connection to the claimant can strengthen your application.
Indicate how you will stay informed about the claimant's needs. Regular visits or living arrangements can demonstrate your involvement.
If the claimant has a legal guardian or conservator, include their information. This helps the Social Security Administration understand the claimant's support system.
Be aware of the need to report any changes in the claimant's living situation or your own circumstances as a payee.
After submitting the form, you must use the benefits for the claimant's current needs or save them for future use.
Failure to comply with the responsibilities of a representative payee can lead to legal consequences, including the requirement to repay misused funds.