The SSA-11-BK has been revised (2/2000) to include new SVB payee reporting responsibilities.
Use the new SSA-11-BK when someone applies to be a payee for a title VIII beneficiary.
Conduct a face-to-face interview whenever practicable. (Refer to GN 00502.113, GN 00502.115, and GN 00505.010.) Explain the payee applicant's reporting responsibilities including accounting requirements.
Give the new SVB payee reporting responsibilities to the payee applicant. If a new
SSA-11-BK is not available, modify the prior version to include SVB by adding "SV"
after "Black Lung" and before "benefits" in the bolded area on page 1. A copy of the
Exhibit can be made in order to give the payee applicant the new SVB reporting responsibilities
(pages 11 and 12 of the SSA-11-BK).
SPECIAL BENEFITS FOR WORLD WAR II VETERANS
Information for Representative Payees Who Receive Special Benefits for WW II
Veterans
YOU MUST NOTIFY THE SOCIAL SECURITY ADMINISTRATION PROMPTLY IF ANY OF THE FOLLOWING
EVENTS OCCUR AND PROMPTLY RETURN ANY PAYMENT TO WHICH THE CLAIMANT IS NOT ENTITLED:
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the claimant DIES (special veterans entitlement ends the month after the claimant
dies);
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the claimant returns to the United States for a calendar month or longer;
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the claimant moves or changes the place where he/she actually lives;
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the claimant receives a pension, annuity or other recurring payment (includes workers'
compensation, veterans benefits or disability benefits), or the amount of the annuity
changes;
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the claimant is or has been deported or removed from U.S.;
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the claimant left a jurisdiction within the U.S. to avoid prosecution or custody or
confinement after conviction for a crime that is a felony, or in New Jersey, a high
misdemeanor;
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the claimant is in violation of a condition of probation or parole.
In addition to these events about the claimant, you must also notify us if
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YOU are convicted of a felony.
BENEFITS MAY STOP IF ANY OF THE ABOVE EVENTS OCCUR. You can make your reports by telephone,
mail or in person. You can contact any Federal Benefits Unit (FBU) or the Regional
Federal Benefits Office in the Philippines or any U.S. Social Security Office.
REMEMBER:
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payments must be used for the claimant's current needs or saved if not currently needed;
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you may be held liable for repayment of any payments not used for the claimant's needs
or of any overpayment that occurred due to your fault;
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you must account for benefits when so asked by the Social Security Administration.
You will keep records of how benefits were spent so you can provide us with a correct
accounting;
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to let us know as soon as you know you are unable to continue as representative payee
or the claimant no longer needs a payee.
Form SSA-11-BK (2-2000) Page 11
A REMINDER TO PAYEE APPLICANTS
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TELEPHONE NUMBER(S) TO CALL IF YOU HAVE A QUESTION OR SOMETHING TO REPORT
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BEFORE YOU RECEIVE A DECISION NOTICE
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SSA OFFICE
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DATE REQUEST RECEIVED
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AFTER YOU RECEIVE A DECISION NOTICE
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RECEIPT FOR YOUR REQUEST
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Your request for Special Benefits for WW II Veterans on behalf of the individual(s)
named below has been received and will be processed as quickly as possible.
You should hear from us within days after you have given us all the information we
requested. Some claims may take longer if additional information is needed.
In the meantime, if you change your address, or if there is some other change that
may affect the benefits
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payable, you-or someone for you-should report the change. The changes to be reported
are listed on the reverse.
Always give us the claim number of the beneficiary when writing or telephoning about
the claim.
If you have any questions about this application, we will be glad to help you.
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BENEFICIARY
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SOCIAL SECURITY CLAIM NUMBER
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THE PRIVACY ACT
We are required by section 205(j) and 205(a) of the Social Security Act to ask you
to give us the information on this form. This information is needed to determine if
you are qualified to serve as representative payee. Although responses to these questions
are voluntary, you will not be named representative payee unless you give us the answers
to these questions.
Sometimes the law requires us to give out the facts on this form without your consent.
We must release this information to another person or government agency if Federal
law requires that we do so or to do the research and audits needed to administer or
improve our representative payee program.
We may also use the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State or local government
agencies. Many agencies may use matching programs to find or prove that a person qualifies
for benefits paid by the Federal government. The law allows us to do this even if
you do not agree to it.
Explanations about these and other reasons why information you provide us may be used
or given out are available in Social Security offices. If you want to learn more about
this, contact any Social Security office.
PAPERWORK REDUCTION ACT STATEMENT
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with
the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995.
We may not conduct or sponsor, and you are not required to respond to, a collection
of information unless it displays a valid OMB control number. We estimate that it
will take you about 10.5 minutes to complete this form. This includes the time it
will take to read the instructions, gather the necessary facts and fill out the form.
Form SSA-11-BK (2-2000) Page 12
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