PDF
Word
Form SSA-623-F6 Representative Payee Report
What Is Form SSA-623?
Form SSA-623-F6, Representative Payee Report , is a form used to report how you as a representative payee use the benefits you receive on behalf of another person who is a Social Security or Supplemental Security Income (SSI) beneficiary. The form was issued by the U.S. Social Security Administration (SSA) on August 1, 2013 , with previous editions obsolete. Download а printable Form SSA-623 through the link below.
Alternate Names:
- Form SSA-623;
- SSA Form 623-F6.
A representative payee is an individual or organization that handles the social security or SSI benefits for a person who is unable to manage them. A representative payee is responsible for ensuring the benefits are spent to pay for the medical expenses and everyday living of the beneficiary. The funds must be spent only on expenses approved by the SSA. The representative payee must keep all records and report on using the beneficiary's funds.
Related Form:
The SSA reviews the usage of benefits by the representative payees regularly. That is why they send the representative payee the Report Form (SSA-623). You must provide all the information required for the period indicated in the document. Use the records you keep to answer the questions.
How to Fill Out Form SSA-623?
Complete and submit the form within 30 days after receiving it. Use black ink when filling out the document. Do not use the dollar sign and show all required amounts in dollars only (do not enter cents). The instructions are as follows:
- Indicate if you were convicted of a felony during the reporting period. If you were, provide the type of crime in the "Remarks" box.
- Answer "Yes" to Question 2 if the beneficiary continued to live with the same person, in the same institution, or alone during the reporting period. If during any part of this period other people or institutions took care of the beneficiary, answer "No" and comment in the "Remarks" box.
- Provide the details on the accounting for beneficiaries for the reporting period. Include total accountable amount, food, housing, and personal items expenses. Enter the total amount of unused benefits, if any. If you did not save any benefits, enter "0." Indicate who decided how to use benefits.
- Fill out Question 4 only if you showed an amount in Question 3D. Indicate the account type and title. If you checked "Other" in Question 4A or B, provide the details in Question 5.
- Sign your name. If you sign with "X," you must have two witnesses to sign too. If the payee is an organization, the document must be signed by an authorized representative only.
- Enter the date. Indicate your daytime phone number.
You will receive the detailed instruction and all completion requirements with the form you must complete. If you need any help with the document, contact the local Social Security office.
Where to Mail Form SSA-623-F6?
The SSA sends an envelope with an enclosed Form SSA-623-F6. Place your completed form in the envelope and return it to the SSA office indicated on the form. Do not include any records like checks or receipts. However, keep them for two years from the date you filed the form. If the SSA requires proof, they will notify you.
You can also submit the form online. The link will be provided with the form. In this case, you can print a copy of your report after completion. You do not need to submit a paper version of Form SSA-623 if you filled out an electronic one.
Download Form SSA-623-F6 Representative Payee Report
1
2
3
4
5
6
