Form SSA-11-BK at a glance
What it is: Form SSA-11-BK is the Social Security Administration's Request to be Selected as Payee.
Who signs: SIGNATURE OF APPLICANT: by signing, 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.
Use it to request that the Social Security, Supplemental Security Income, or Special Veterans Benefits for the claimant(s) named on it be paid to you as representative payee.
A filled-in Form SSA-11-BK example: a mother applies to be payee for her young daughter
How to fill out Form SSA-11-BK, box by box
The name of the number holder and the person for whom you are filing
Print in ink the name of the number holder and the Social Security number, then the name of the person(s) for whom you are filing (the "claimant(s)") if different from the number holder, with the Social Security number (s).
1. I request that I be paid directly
Answer item 1 only if you are the claimant and want your benefits paid directly to you: check it and answer only items 3, 5, 6, and 8 before signing the form on page 5.
2. Explain why you think the claimant is not able to handle his/her own benefits, and 3. why you would be the best representative payee
2. Explain why you think the claimant is not able to handle his/her own benefits, and describe how he/she manages any money he/she receives now. Check Claimant is a minor child when the claimant is a minor child.
3. Explain why you would be the best representative payee, and use Remarks if you need more space.
4. How will you know about the claimant's needs
4. If you are appointed payee, how will you know about the claimant's needs? Check Live with me or in the institution I represent, Daily visits, Visits at least once a week, or By other means.
5. A court-appointed legal guardian/conservator
5. Does the claimant have a court-appointed legal guardian/conservator? Check Yes or No. If Yes, enter the legal guardian/conservator's Name, Address, Phone Number, Title and Date of Appointment, and explain the circumstances of the appointment (use remarks if you need more space).
6. Where does the claimant live
6. (a) Where does the claimant live? Check Alone; In my home, With a relative, With someone else or In a board and care facility (Go to (b).); or In a public institution, In a private institution, In a nursing home or In the institution I represent (Go to (c).).
(b) Enter the names and relationships of any other people who live with the claimant.
(c) Enter the claimant's residence and mailing addresses (if different from yours) and the telephone number.
(d) Do you expect the claimant's living arrangements to change in the next year? Check Yes or No. If Yes, explain what changes are expected and when they will occur (use Remarks if you need more space).
8. Relatives or close friends who have provided support
8. List the names and relationship of any (other) relatives or close friends who have provided support and/or show active interest with the claimant. Describe the type and amount of support and/or how interest is displayed.
9. Your relationship to the claimant
9. Check the block that describes your relationship to the claimant: (a) Official of bank, agency or institution with responsibility for the person, Parent, Spouse, Other Relative - Specify, Legal Representative, Board and Care Home Operator, or Other Individual - Specify.
IF (a) is checked, complete only questions 10 and 11 and sign the form on page 5. IF (b), (c), (d), or (e) is checked, go on to question 12.
10. Does the claimant owe you/your organization any money
10. Does the claimant owe you/your organization any money now or will he/she owe you money in the future? Check Yes or No. If Yes, enter the amount he/she owes you/your organization, the date(s) was/will be incurred and describe why the debt was/will be incurred.
12. Your name
Individuals applying to be representative payee: 12. Enter: Your name, Date of birth, Social Security Number, Any other name you have used, Other SSN's you have used.
15. Main source of your income
15. (a) Main source of your income: check Employed (answer (b)), Self-employed, Social Security benefits, Pension, Supplemental Security Income payments, Temporary Assistance For Needy Families (TANF), Other State or Public Assistance or Other. (b) Enter your employer's name and address, and how long you have been employed by this employer. (If less than 1 year, enter name and address of previous employer in Remarks.)
16. Criminal background check, 17. convicted and 18. warrants
16. Do you give Social Security permission to conduct a criminal background check on you? Check Yes or No.
17. (a) Have you ever been convicted of a felony? (b) Have you ever been convicted of any offense under federal or state law which resulted in imprisonment for more than one year? Check Yes or No. If Yes: What was the crime? On what date were you convicted? What was your sentence? If imprisoned, when were you released? If probation was ordered, when did/will your probation end?
18. Do you have any unsatisfied FELONY warrants (or in jurisdictions that do not define crimes as felonies, a crime punishable by death or imprisonment exceeding 1 year) for your arrest? Check Yes or No. If Yes: Date of Warrant; State where warrant was issued.
19. How long have you lived at your current address
19. How long have you lived at your current address? (Give Date MM/YY) REMARKS: (This space may be used for explaining any answers to the questions. If you need more space, attach a separate sheet.)
Signature, DATE, Mailing Address and Residence Address
Write in ink the Signature (First name, middle initial, last name) with the DATE (MM/DD/YYYY), the Telephone number(s) at which you may be contacted during the day, and Print Your Name & Title (if a representative or employee of an institution/organization).
Enter your Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route) and your Residence Address, each with City and State, ZIP Code and Name of County.
Witnesses
Witnesses are only required if this application has been signed by mark (X). If signed by mark (X), two witnesses to the signing who know the applicant making the request must sign, giving their full addresses.
Common questions about Form SSA-11-BK
Is there a penalty?
I/my organization may be held liable for repayment if I/my organization misuse the payments or if I/my organization am/is at fault for any overpayment of benefits. I/my organization may be punished under Federal law by fine, imprisonment or both if I/my organization am/is found guilty of misuse of Social Security or SSI benefits.
Sources
[1] Form SSA-11-BK (09-2020), Request to be Selected as Payee, Social Security Administration (the served file; no issuer file) (the Official source link on this page).
