Fill in the following:

• •

  Payee Name and Address;

• •

  Beneficiary Social Security Number;

• •

  Report Period (FROM: and TO: dates); and

• •

  Beneficiary Name

Fill in the following:

• •

  Benefits paid during the report period;

• •

  Benefits reported as saved from prior years; and

• •

  Total Accountable Benefits Amount

Fill in the following:

• •

  Past-due SSI benefits SSA deposited in Dedicated Account during the report period;

• •

  Balance in Dedicated Account as reported on a prior report; and

• •

  Total Dedicated Account Amount

IMPORTANT:When the system determines a dedicated account based on the payment amount (PMTH), it is assumed that field office (FO) personnel paid the past-due benefits into a dedicated account but failed to establish the indicator(s) “'X, 1, 2, or F” in pay flag 5. Some over-selection of potential dedicated account cases may occur since the systems selection process did not consider individual State supplement payments in computing the amount required to establish a dedicated account (due to the large variance in State supplement amounts). Therefore, dedicated accounts were never actually established for these over-selected cases. When computing the dedicated account information, if you determine that the past-due benefits meet the dedicated account criteria, include this amount under SSA Deposited in Dedicated Account for question 6 above. If you determine that the past-due benefits did not meet the criteria for a dedicated account, obtain an annual accounting SSA-623, and update the SSR following the instructions in GN 00605.230B.1., DI Diary Set-No Dedicated Account Exists.

Mail the SSA-6233-BK to the payee for completion. The report can also be completed through telephone contact and mailed to the payee for signature, or in a face-to-face interview, if FO resources permit.

Completed SSA-6233-BKs must be retrievable in the event a report is needed in a misapplication, misuse, or fraud investigation. The FO must store the completed SSA-6233-BK in the Non Disability Repository (NDRED) using the Evidence Portal(EP). Once the report has been stored, the paper SSA-6233 does not need to be retained. See MS 09701.001 Evidence Portal- Overview.

REMINDER: Do not send the completed SSA-6233-BK to the Program Centers or the Wilkes-Barre Direct Operations Center for storage.