Form SSA-11-BK Request to Be Selected as Payee

How to Fill Out SSA-11-BK Form?

If the payee's services are no longer required by the beneficiary, they should file a request fordirect payment using this form. The SSA will require their physician to fill outForm SSA-787, Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits, to obtain information about the beneficiary's ability to manage funds.

Filing Form SSA-11-BK is the first step in becoming a representative payee. The SSA also requires a face-to-face interview, phone interview, or video service delivery interview. The application should be filed via the Electronic Representative Payee System (eRPS). The paper version of the application is used only if the eRPS is unavailable or it is impossible to use it.

Form SSA-11-BK instructions are as follows:

1. Enter your name and Social Security Number (SSN) as well as the name of the beneficiary and their SSN in the heading of the form.
2. Item 1 applies to the beneficiary onlyю Check the box if you are filing a request for direct payment.
3. Provide an explanation as to why the beneficiary requires a representative payee in Item 2. If they are a minor child, check the box;
4. Provide a reason why you should be chosen as a representative payee for that person in Item 3. If the provided space is not enough, use the Remarks section.
5. Check the applicable box to indicate the way you will know about the beneficiary's needs in Item 4.
6. Specify whether the beneficiary has a court-appointed legal guardian in Item 5. If the answer is positive, provide the name, address, phone number, and title of this person and the date they were appointed. Describe the circumstances of the appointment.
7. Check the applicable box indicating the beneficiary's place of residence in Item 6A. Check Item 6B if the beneficiary lives with other people. Provide their names and the relationship to the beneficiary. Item 6C applies if the beneficiary lives in an institution. Provide the name, mailing address, and phone number of this institution. Check the applicable box in Item 6D to indicate whether the beneficiary's living arrangements are to be changed in the next year. Provide an explanation in the "Remarks" section.
8. Item 7 should be filled if the applicant desires to become a representative payee of a minor child and they are not the child's parent. Specify whether the child has a living natural or adoptive parent. If the answer is positive, provide their name, address, phone number and indicate whether the parent shows interest in the child. Provide an explanation.
9. Enter the names and addresses or phone numbers of people who show an active interest in the beneficiary in Item 8.
10. Check the box indicating your relationship to the beneficiary in Item 9. If you checked any box under "A," complete Items 10 and 11 only. If any other option is chosen, skip these items and go to Item 12.
11. Indicate whether the beneficiary owes you or the organization you represent any money in Item 10. If they do, provide the information about the debt: its amount, the date it occurred, and how it is going to be incurred.
12. Enter the name of the institution, agency, or bank you represent and the Employer Identification Number (EIN) of the organization in Item 11.
13. Provide your name, date of birth, SSN, names, and SSNs you used in the past, if any, in Item 12.
14. Provide information about how long you have known the beneficiary in Item 13.
15. Provide the information about the person taking the beneficiary to work or any other outside activity in Item 14. Specify the relationship between this person and the beneficiary.
16. Check the box indicating your main source of income in Item 15A. Enter the name and address of your employer if you are employed in Item 15B. Specify the duration of your employment.
17. Check the box indicating whether you have ever been convicted of a felony in Item 16A. The positive answer must be followed by the information about the crime: when you were convicted, what was the sentence, were you imprisoned and (if you were) when you were released, and if prohibition was ordered when it will end. Indicate whether you have ever been imprisoned for more than one year in Item 16B. If you were, provide information about the crime, the sentence, when were you released and when the prohibition will end, in case it was ordered.
18. Indicate whether you have any unsatisfied felony warrants in Item 17. If you have, enter the date of the warrant and the place it was issued;
19. Enter the date you moved into your current house in MM/YY format in Item 18.

Sign and date the form. Provide your phone number. Enter your mailing address and residence address. If you are a representative of an organization, print your name and title.