Form SSA 11-BK

Form SSA 11-BK, Request to Be Selected as Payee, is a form completed and returned to the Social Security Administration. The purpose of this form is to another person be named as payee other than the payee. This form is used when the original payee is unable to manage their own finances. In addition to completing and submitting this form, the individual requesting to be named as a representative payee must also attend a face to face interview.

What is a SSA 11-BK?

This form will be used by the Social Security Administration in the United States. A Form SSA 11-BK is known as a Request to be Selected as Payee. It will be used by someone who wants to become a representative payee for another payee. This form must be completed in a face-to-face interview with someone from the Social Security Administration in order to determine eligibility and suitability.
This form will require personal information about the person applying to be a representative payee. This includes their name, social security number, and contact information. The applicant will also need to have information regarding the person they want to represent. This includes the reason they believe the party is unable to manage their own finances.

How to complete an SSA 11-BK (Step by Step)

To complete an SSA 11-BK, you will need to provide the following information:

  • Name of the number holder
  • Social security number
  • Name of the person(s) for whom you are filing (claimant)
  • Claimant’s social security number
  • Indication if you are the claimant and what your benefits paid directly to you
  • Explanation if you think the claimant is not able to handle his or her own benefits
  • Explanation why you would be the best representative payee
  • If you are appointed the payee, indicate you will know about the claimant’s needs
  • Whether the claimant has a court-appointed legal guardian or conservator
  • Name, address and date of appointment of guardian or conservator 
  • Circumstances of appointment
  • Claimant’s type of residence
  • Names and relationships of any other people who live with the claimant
  • Claimant’s residence address and phone number
  • Whether you expect the claimant’s living arrangement to change in the next year
  • Whether you are applying on behalf of minor child(ren) and you are not the parent
  • Parent’s information and explanation of whether parent shows interest in child
  • Names and relationships of other relatives or close friends with active interest in claimant
  • Indication of your type of relationship to the claimant
  • Whether the claimant owes you/your organization money now or will in the future
  • Institutions, agencies, and banks applying to be the representative payee: name, EIN
  • Individuals applying to be the representative payee: name, date of birth, social security number, another other names used, any other SSNs used
  • Length of time you have known claimant
  • If claimant lives with you, indicate who takes care of the claimant while you are away and their relationship to claimant
  • Main source of your income
  • Employer’s name and address
  • Length of employment
  • Whether you have ever been convicted of a felony, details of crime, sentence, release, probation
  • Whether you have any unsatisfied felony warrant for your arrest
  • Length of time at current address
  • Signature
  • Date
  • Address
  • Signature of witness

Sample Form SSA 11-BK


Sample Form SSA 11-BK

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