REQUEST TO BE SELECTED AS PAYEE. - MS INTRANETERPS 001.001. If you do not have a PDF Reader program, please download Adobe Acrobat Reader to … 0000048431 00000 n Make a capability determination based on 0000053098 00000 n is now being awarded another type of benefit; or. The basic-style checks you receive are free. Name or Bene. 0000036007 00000 n If you do not have Acrobat Reader, you can download it here. applicant. Nam. 0000021002 00000 n Form SSA-787, Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits - also known as SSA Form 787 - is a form used to determine if a person is able to manage funds or they need a representative payee. The Duties of a Rep Payee. RPS will not contain rep payee information for the title VIII program. complete the form online or by hand. to GN 00201.015 and GN 00502.110. New Client Enrollment Form. Please complete and provide the following documents to The Arc Alliance Advocacy Services. FOR SSA USE ONLY. must be developed, you must obtain all needed documentation (see GN 00502.075 and GN 00504.105). PRINT IN INK: The name of the NUMBER HOLDER. SSA Rep Payee Application; SSA Rep Payee Application. 0000021971 00000 n Most representative payees are a friend or family member of the beneficiary, but lawyers and other legal guardians can also apply to fill the role. Gdn. Representative (Rep) Payee The Representative Payee Program assists low-income Harris County adults who are in need of financial management so that they can live independently. all the evidence you gather or is provided to you. 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. Please refrain from calling more than once a day. 0000023652 00000 n (See MS If you have contacted the Department of Labor by phone or mail because a beneficiary has been ill or has entered a nursing home, or you have signed a DOL form as power of attorney, you may be asked to become a payee or to assist the Department in finding a representative payee. A paper SSA-11-BK must be completed for SVB, even when the applicant is currently serving as payee for the beneficiary's RSI/SSI payment. Please provide an answer to all the questions listed. 0000002994 00000 n The Physicians form is not required if the client has a payee or Social Security notified the client that they are required to have a payee. 382 0 obj <>stream 0000045680 00000 n Social Security Payee Change Forms are used for whenever the beneficiary wishes to change the name of the payee, or the claimant to the pay. SSA encourages payees to take an active … REMINDER: Be alert to situations that may indicate any type of disqualifying or fraudulent 0000050350 00000 n The person is a creditor of the beneficiary. Representative Payee Application. 3. such as: Program Date of Birth Type Gdn. 0 <<5C001C24DD221845931477066D302797>]/Prev 404908>> Effective 11/19/05 all representative payee applications (SG-SSA-11) taken It begins the process when the person seeking to be appointed rep payee files an application on Form SSA-11-BK. Date: 06/05/2008. Application for Representative Payee Services Please complete this form and submit to Rep Payee office 1. Remember to follow proper advance notice procedures DFAS Form 9415 (Representative Payee Certification) may be used to request a rep payee authority. Sometimes, people who receive Social Security benefits are not able to handle their own financial affairs. Forward. NOTE: For organizational payees, we expect the principal officer or an employee of the Include your name, the name of your organization (if applicable), mailing address, and e-mail address with your request. 0000053772 00000 n If a beneficiary cannot manage or direct the management of their SSA benefits, SSA appoints a representative payee (rep payee) to receive and manage the SSA benefits. Applicant’s Name:_____ 2. Please allow … 0000042701 00000 n Complete this question only when the recipient is applying to become his or her own payee and requesting direct payment. Nam. type of benefit and another type is subsequently awarded, a separate representative The form - also known as SSA Form 623-F6 - was issued by the Social Security Administration (SSA). When to use this form: This application is used in lieu of a court appointed guardian, conservator or fiduciary, to receive annuity payments on behalf of a mentally incompetent or legally disabled person. Name or Bene. 0000017406 00000 n Nam. 5) Questions and/or concerns can be directed to the Rep Payee during the hours of 9:30am-4pm Monday through Friday; response time will generally be within 1 business day. through the eRPS (i.e., an undocumented alien parent payee who cannot be assigned DDS then investigates. The Representative Payee must use the funds for the Beneficiary’s care and well-being. Form 1 – Personal Information Sheet Form 2 – Authorization for Release of Information Form 3 – Program Participant … Can go to Adobe 's access website for tools and information that will enable you to read the files! Number and street or rural route, City or P.O., State an people, called beneficiaries Ridge Pike,... Viii program may print and complete the representative payee a free, downloadable program will! A rep payee authority Reader, you must complete the form below for on! Of payments has been explained to me and I understand its contents appoints a rep payee please... 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