SSA-11

Request To Be Selected As Payee

Download and Print the SSA-11

FOR SSA USE ONLY
Name or Bene. Sym. - Program - Date of Birth - Type - Gdn. - Cus. - Inst. - Nam.

FOR SSA USE ONLY - DISTRICT OFFICE CODE - STATE AND COUNTY CODE:

PRINT IN INK:

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 "claimant(s)")
SOCIAL SECURITY NUMBER(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 4.

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:

And much more...