TN 43 (04-16)

GN 00502.115 The SSA-11-BK, Request to be Selected As Payee

A. Policy

The SSA-11-BK is the paper form a potential payee completes to apply to be payee. Use the SSA-11-BK only when it is not possible to use the eRPS. For example, applications for undocumented aliens must be taken on the paper form.

NOTE: Faxed, mailed, or dropped off SSA-11’s are leads. You must follow up with a face-to-face interview, telephone interview or video service delivery (VSD) interview. For information on subsequent face-to face interviews see GN 00502.113B.2.

REMEMBER: Payee applications must be taken in the eRPS whenever possible (MS INTRANETERPS 001.001 for individual payee applicants and MS INTRANETERPS 014.001 for organizational/institutional payee applicants). When a paper application is taken because the system is temporarily unavailable, process the application through eRPS when the system becomes available.

To the extent practicable, the SSA-11-BK must be completed in a face-to-face interview. This section describes the expected answers to the questions on the SSA-11-BK and how to evaluate those answers. (for undue hardship or subsequent face-to-face interviews, see GN 00502.113).

For procedures on processing manual payee actions, see GN 00502.190, for procedures on storing the SSA-11-BK see GN 00502.110C.

NOTE: Where the beneficiary dies before the SSA-11 is completely processed, FOs should handle the SSA-11 as incomplete, and notify the payee applicant of the action taken (see GN 01010.475 and GN 00502.110C.10).

B. Exhibit of the SSA-11-BK (Page 1)

The following is an exhibit of form SSA-11-BK, Request to Be Selected as Payee (Page 1)

G-GN_00502.115B-1

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C. Description of entry or expected answer

Use the following chart to determine what information is expected in answer to specific questions on page 1 of the SSA-11-BK and how to evaluate those answers.

QUESTION

EXPLANATION

Heading

Enter appropriate payee coding (see SM 01601.565).

NOTE: Coding is needed for all beneficiaries when a representative payee is appointed.

Enter the number holder's name and SSN and the beneficiary (ies) name(s) and SSN(s).

1

Complete this question only when the beneficiary in representative payment requests direct payment.

2

Use in conjunction with other evidence of capability to decide whether the beneficiary needs a representative payee. Obtain information about:

  • how the beneficiary is handling any money now received,

  • how the beneficiary interacts with society, and

  • any other information which will help you to judge the beneficiary's ability to make reasonable judgments about managing funds.

Direct payment is precluded—you only need to state the precluding condition.

Minor children—check the indicator block.

3

This will help you decide if the applicant is the best possible payee.

Obtain information about how the applicant shows interest in and demonstrates responsibility for the beneficiary.

4

This will help you decide if the applicant is the best possible payee.

5

These answers are needed to identify possible higher preference payees and any third party that must receive notice.  
ALERT: Appointment of a legal guardian by a court may indicate that the beneficiary is legally incompetent (see GN 00502.005A.2. and GN 00502.130B.).

D. Exhibit of the SSA-11-BK (Page 2)

The following is an exhibit of form SSA-11-BK, Request to Be Selected as Payee (Page 2)

G-GN_00502.115B-2

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E. Description of entry or expected answer

Use the following chart to determine what information is expected in answer to specific questions on page 2 of the SSA-11-BK and how to evaluate those answers.

QUESTION

EXPLANATION

6

This may supply information relevant to your capability decision and may indicate other potential payee sources. It is also used to identify the custodian.

7

This may provide a lead to a candidate higher on the preference list. (A parent with custody of a minor child is generally the preferred payee for that child.)

8

The names gathered here are potential payee leads.

9

This serves to identify payee type (and thus indicates if additional development is needed) and to determine which of the remaining questions the applicant must complete.

F. Exhibit of the SSA-11-BK (Page 3)

The following is an exhibit of form SSA-11-BK, Request to Be Selected as Payee (Page 3)

G-GN_00502.115B-3

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G. Description of entry or expected answer

Use the following chart to determine what information is expected in answer to specific questions on pages 3 and 4 of the SSA-11-BK and how to evaluate those answers.

QUESTION

EXPLANATION

10

See GN 00502.135

11

Only institutions, agencies and financial institutions answer this. It will capture identifying information about the applicant.

12

This will supply information about the applicant that will be used to verify the applicant's SSN and identity. An SSN is required from an individual (see GN 00502.117). Do not request the SSN if the applicant is filing as an official representing an institution or organization. Instead, obtain the EIN of the institution/organization the applicant represents (question 10). For additional EIN information, see GN 00502.118 and MS INTRANETERPS 014.002 Establish Organization/Institution screen.

13

This will be useful in assessing how long the applicant has known the beneficiary.

14

This will help you assess the applicant's suitability and may elicit other potential payee leads.

15

This will help you assess the payee applicant’s income situation and may factor in how the likely the applicant will use the benefits in the best interest of the beneficiary.

16

This will help you assess an applicant’s criminal history after the applicant gives permission to run a criminal background check. For additional instructions see GN 00502.113D.1.

17

See GN 00502.133 for additional instructions on the use of the answers to this question.

18

See GN 00502.133A.2.

19

This may help in assessing the applicant's stability in the community, a factor that bears on suitability as payee. However, you should obtain additional information about the situation surrounding the change of address to determine if it has any bearing on applicant's suitability. 

For an applicant who has merely changed his or her fixed address recently from another fixed address, change of address is not an indicator of unsuitability as payee. However, if an applicant changes residence frequently, the applicant may have no true fixed address. While this does not necessarily indicate the applicant is unsuitable, a transient lifestyle may raise some question about the applicant's suitability.

H. Exhibit of the SSA-11-BK (Page 4)

The following is an exhibit of form SSA-11-BK, Request to Be Selected as Payee (Page 4)

G-GN_00502.115B-4

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I. References

eRPS Overview MS INTRANETERPS 001.001 – MS INTRANETERPS 020.023 PC Processing of T2R Output and Manual Payee Actions-

GN 00502.190 Signature and retention requirements - GN 00502.110C.

Final Notice - GN 00503.130B


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0200502115
GN 00502.115 - The SSA-11-BK, Request to be Selected As Payee - 04/15/2016
Batch run: 04/15/2016
Rev:04/15/2016