Form SSA-6233-BK at a glance
What it is: Form SSA-6233-BK, the Representative Payee Report of Benefits and Dedicated Account, is about the benefits you received for the beneficiary and those deposited in the dedicated account during the report period.
Who signs: Be sure you, the representative payee, sign the form.
Social Security must regularly review how representative payees used the benefits they received on behalf of Social Security and/or Supplemental Security Income (SSI) beneficiaries.
As part of this review, you need to answer the questions on the enclosed form.
A filled-in Form SSA-6233-BK example: a payee reports a year of benefits
How to fill out Form SSA-6233-BK, box by box
Report period and mailing address
Report Period - The 12-month period shown on the report for which you must account for the benefits you received and report on the dedicated account.
Please review the mailing address and correct if necessary.
The payee convicted of a felony
If during the report period you (the payee) were convicted of a crime considered to be a felony, place an "X" in the "YES" box and explain the type of crime.
Otherwise, place an "X" in the "NO" box.
Where the beneficiary continued to live
If the beneficiary continued to live alone, or with the same person, or in the same institution during the entire report period, place an "X" in the "YES" box.
Place an "X" in the "NO" box if different people, or different institutions took care of the beneficiary during any part of the report period.
Explain the change and provide the beneficiary's current address.
The total accountable benefit amount
Do not use dollar signs. Show money amounts in dollars only. Do not show cents.
The total accountable benefit amount includes the benefits you received during the report period plus any benefits you reported as saved on last year's report.
The payee decided how the benefits were spent or saved
If you (the payee) decided how the benefits were to be spent or saved, place an "X" in the "YES" box.
Place an "X" in the "NO" box if the beneficiary or someone else decided how to use the money, and explain in the space provided.
B. Food And Housing
B.Food And Housing Show the total amount of benefits spent for food and housing for the beneficiary during the report period.
If the beneficiary lives in an institution or nursing home and you pay monthly charges, multiply the monthly charge by 12 and show this amount.
C. Personal Items
C.Personal Items Show the total amount of benefits spent for the beneficiary on clothing, medical/ dental care, education, and recreational items like toys, movies, cameras, radios, candy, stationery, grooming aids, etc. during the report period.
If the beneficiary lives in an institution or other care facility, you should spend at least $360 a year for the beneficiary's personal needs. If you spent less than $360, explain in the space provided. (checked November 10, 2026)
D. Unused Benefits
D.Unused Benefits Show the total amount of benefits you have saved for the beneficiary at the end of the report period, including any interest earned.
How you are saving the benefits
Answer this question if you showed an amount in 3.D.
If you have more than one account, you may mark more than one box in each section.
A.Type of Account Place an "X" in the box which shows how you are saving the benefits.
B.Account Title Place an "X" in the box which most accurately describes the wording of the account title you have on the beneficiary's savings.
Question 5 - Other Savings/ Account Titles
Answer this question only if you checked "Other" in 4.A. or 4.B.
Show the title of the account if the savings are in an account or other investment. Show "None" if the savings are not in an account or investment.
Money deposited into the dedicated account
The total dedicated account amount includes the past-due SSI benefits SSA deposited into the account during the report period plus the balance in the account as you reported on last year's report.
If you deposited any money into the dedicated account during the report period, place an "X" in the "YES" box.
Show the date and amount of each deposit.
Place and "X" in the "NO" box if you did not deposit any money into the account.
Took money out of the dedicated account
If during the report period you took money out of the dedicated account, place an "X" in the "YES" box.
Explain what items and/or services you purchased and the amount of each purchase.
Place an "X" in the "NO" box if no money was removed from the account.
B. How Is Purchase Related To Impairment?
Answer this question if you checked "YES" in 7.A.
If the items and/or services purchased were for medical treatment, or education or job skills training, place an "X" in the "YES" box.
Place an "X" in the "NO" box if the purchases were for something else and explain how the purchases benefited the beneficiary and are related to his/her impairment(s).
Balance in the dedicated account
Show the balance in the dedicated account at the end of the report period, including any interest earned.
Show zeroes if there is no money in the account.
Payee's Signature
Sign your name in this block.
If you sign by mark ("X"), please have two witnesses sign their names and show the date.
Witness signatures are required only if the payee's signature has been signed by mark (X).
If the payee is an institution or agency, the form must be signed by an authorized person.
You declare under penalty of perjury that you 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 your knowledge.
Show your relationship to the beneficiary. If you are the beneficiary's legal guardian, show "legal guardian". If you represent a bank, institution or agency, show your job title (e.g., administrator, bookkeeper, etc.).
More rules for Form SSA-6233-BK
You should keep these records (e.g. bank statements and canceled checks) along with receipts for two years from the time you complete the form.
Do not submit any records with the completed form.
If you do not return it promptly, payments to you may stop.
Common questions about Form SSA-6233-BK
Is there a deadline?
Complete the report and send it in the enclosed envelope within 30 days.
Where do I file it?
Send the completed form to your local Social Security office.
Is there a penalty?
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.
Sources
[1] Form SSA-6233-BK (07-2010), Representative Payee Report of Benefits and Dedicated Account, Social Security Administration (the Official source link on this page).