The FO conducts face-to-face interviews with the payee, the beneficiary, and/ or the custodian. If the payee and the beneficiary or custodian are served by separate FO's, the FO serving the payee completes Parts I and IV, and the FO serving the beneficiary or custodian completes Parts II and III. (See GN 00501.015E. for discussion of resident FO.) Each claims or service representative who conducts an interview will sign Part IV. The SSA-624-F5 is available electronically via eForms.

Form SSA-624-F5, Representative Payee Evaluation Report, Part I (Page 1)

Page 2

REFERENCE: Follow GN 00605.061C. to complete identifying data preceding the interview questions.

Form SSA-624-F5, Representative Payee Evaluation Report, Part II (Page 3)

Interview the beneficiary and complete Part II unless  it is medically impractical or the beneficiary is under age 15.

If possible, interview the beneficiary and obtain responses to the items in Part II. Otherwise, explain in Remarks (item 5) why a beneficiary interview is not possible or is not complete.

Form SSA-624-F5, Representative Payee Evaluation Report, Part III (Page 4)

Use Part III if the payee and the custodian are not the same person or organization and:

• •

  the FO could not complete Part II; or

• •

  there is a discrepancy between the payee's responses (Part I) and the beneficiary's responses (Part II).

If there was more than one custodian during the report period, interview the one who had custody for the longest period of time.