Ssa 623 Representative Payee Report Form Details

Form SSA 6232 is an important form that every Social Security Disability claimant should know about. This form is used to request a reconsideration of your claim after your initial application has been denied. It's important to understand how the form works and what information needs to be included in order to have the best chance of having your claim approved. In this blog post, we'll walk you through everything you need to know about Form SSA 6232.

You will see info about the type of form you wish to fill out in the table. It will show you how much time you will need to complete form ssa 6232, what fields you will need to fill in and some other specific details.

QuestionAnswer
Form NameForm Ssa 6232
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesssa 623 form, ssa 623 representative payee report form, ssa 623 representative payee report, form ssa 623 ocr sm

Form Preview Example

6232

Representative Payee Report

Social Security Administration, P.O. Box 6230,Wilkes-Barre. PA 18767-9956

FORI"l APPROVED OI'vIBNO mlGO-OOG8

PAYEE'S NAME AND ADDRESS

REPORT PERIOD

 

 

 

SOCIAL SECURITY NUMBER

 

FROM:

 

 

TO:

 

 

 

 

 

BENEFICIARY

 

 

 

 

 

FP

 

ID

BIC

D

TP

CC

GS

PC

DOC

 

CF

 

TAA

PF

 

BSSN

 

 

If change at'address, check box and

0

 

 

 

 

 

 

 

enter new address on back of report.

 

 

 

 

 

 

 

This report is about the benefits you received between

 

and

 

for the beneficiary,

 

. Please read the enclosed instructions before completing this fonn to help you answer each question.

Were you (the payee) convicted of a crime considered to be a felony between 1. and ?

If 'YES, please explain in REMARKS on the back of this form.

Did the beneficiary continue to live alone, or with the same person, or in the same

2. institution from to ?IfNO, please explain and provide the beneficiary's current address in REMARKS on the back ofthis form.

3.

Benefits

paid to you between

and

=$

Benefits

you reported as saved on last

year's report.

=$

 

Total Accountable Amount

 

=$

A

Did you (the payee) decide how the $

was spent or saved?

..

If NO, please explain in REMARKS on the back of this form.

 

 

How much ofthe $

did you spend for the beneficiary'Sfoodand

..

B. housing between

 

and

?

 

 

How much of$

did you spend on other things for the

 

..

 

beneficiary such as clothing, education, medical and dental expenses,

c. recreation, or personal items between

and I

?

D.

How much, ifany, of the $

did you save for the beneficiaryas of

)LI-

? If none, show zeros.

 

 

YES NO

D D

D

YES NO

D D

DOLLAR AMOUNT

(NO CENTS)

I I I I , I I I I

I I I I , I I I I

I I I I , I I I I

4.

Savingsl

Checking

Account.

D

If you showed an amount in 3.D. above, place an "x" in the boxes below to show how you are saving the benefits. If you have more than one account, you may mark more than one box in each section.

A. TYPE OF ACCOUNT

 

B. TITLE OF ACCOUNT

US. Savings

Certificates

Collect.ive So vingsl Treasury

 

Beneficiary's Name

Your Name for

 

Bonds

of Deposit

Bheokfnr; Account

Bills

OTHER

by Your Name

Honefici ary's Name

Other

D

D

D

D

o

D

 

D

«'OHMSSA-623-0CR-SM (02-2012)

Continued on the Reverse ----

.-~

62328

FOR SSA USE ONLY

A'1"l'D rVIAHKD SIGD UNDID UND2D O'I'UO

5.A.

Answer this question onlyifyou answered "OTHER"

in 4.A.on the front page. If you answered "OTHER"in

 

4.A. show the type of account.or investment inwhich

 

the benefits are saved.

.....

B

. Answer t.hisquestion onlyifyou answered "OTHER"-

in 4.B.on the front page. IfyOLI answered "OTHER"in

4.B.,show the title ofthe account.in which the benefits

 

are saved

....

REMARKS

 

--

 

 

NEW ADDRESS

T'{PE OF ACCOUNT

TITLE OF ACCOUNT

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to 'prison, or may face other penalties, or both.

PAYEE'S SIGNATURE

DATE

(If'signed by mark ("X"),two witnesses must sign below)

7.

 

 

DAY'IiIME TELEPHONE NUMBER(S)

 

(Include area code)

6.

\VITNESS SIGNATURES SIGNATURE OF WITNESS

8. Area Code -

ARE RE~IRED ONLY IF THE PAYEE'S SIGNATURE ABOVE HASBE ~'. SIGNED BY MARK RRYR').

DATE

SIGNATURE OF' WITNESS

DATE

-FORM SSA-623-0CR-SM (02·2012)

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