TN 15 (02-90)

NL 00804.185 Representative Payee

1. 1290. 

   Situation Where Used:

Notice to selected representative payee.

 

We have decided that Supplemental Security Income payments for    (1)    will be sent to you. By regulation, all payments are to be used for    (2)    well-being and benefit. As representative payee for this individual, you have certain reporting responsibilities. You should read the enclosed pamphlet carefully.

 

1. (1) 

   (Recipient's Name)

    

2. (2) 

   Choice 1 - her

   Choice 2 - his

    

1. 1291. 

   Situation Where Used:

IC and PE: Notice to legally competent SSI recipient regarding selection of payee, with copy to representative payee. For manual notices, use this paragraph to notify a legal guardian also.

 

We have determined that    (1)    will be paid to    (2)    who is interested in or concerned with    (3)    . This representative payee has agreed to receive and manage these payments for    (4)    use and benefit.

 

1. (1) 

   Choice 1 - your Supplemental Security Income payments

   Choice 2 - Supplemental Security Income payments for (Recipient's Name)

    

2. (2) 

   (Name and address of the Representative Payee)

    

3. (3) 

   Choice 1 - your well-being

   Choice 2 - her well-being

   Choice 3 - his well-being

   Choice 4 - the well-being of the recipient

    

4. (4) 

   Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

1. 1292. 

   Situation Where Used:

Notice to recipient determined to be DA and A that a representative payee has been selected.

 

The medical evidence has been reviewed and it has been determined that     (1)    disabled. Because    (2)    contributes to the finding of    (3)    disability, the law requires that    (4)    receive payments through another person or agency. Based on information we have received, we have determined that    (5)    Supplemental Security Income payments will be paid to    (6)    who is interested in or concerned with    (7)    This representative payee has agreed to receive and manage these payments for    (8)    .

 

1. (1) 

   Choice 1 - you are

   Choice 2 - (name of disabled person) is

    

2. (2) 

   Choice 1 - alcoholism

   Choice 2 - drug addiction

   Choice 3 - alcoholism and drug addiction

    

3. (3) 

   Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

4. (4) 

   Choice 1 - you

   Choice 2 - she

   Choice 3 - he

    

5. (5) 

   Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

6. (6) 

   (Name of representative payee selected)

    

7. (7) 

   Choice 1 - your well-being.

   Choice 2 - the well-being of the recipient.

    

8. (8) 

   Choice 1 - your use and benefit

   Choice 2 - the use and benefit of (name of disabled person)

    

1. 1608. 

   Situation Where Used:

Notice to representative of his/her selection to receive payments that may be due in the future.

 

We have decided that any Supplemental Security Income payments which may be due in the future for    (1)    will be sent to you. By regulation, all payments are to be used for    (2)    well-being and benefit. As representative payee for this individual, you have certain reporting responsibilities. You should read the enclosed pamphlet carefully.

 

1. (1) 

   (Name of recipient)

    

2. (2) 

   Choice 1 - her

   Choice 2 - his

    

1. 1609. 

   Situation Where Used:

IC and PE: Notice to legally competent SSI recipient regarding selection of payee, with a copy to the representative payee. For manual notices, use this paragraph to notify a legal guardian also.

 

We have determined that any Supplemental Security Income payments which may be due in the future for    (1)    will be paid to    (2)    . This person is interested in or concerned with    (3)          (4)    has agreed to receive and manage any payments     (5)     for    (6)    use and benefit.

 

1. (1) 

   Choice 1 - you

   Choice 2 - (Name of recipient)

    

2. (2) 

   Choice 1 - (Name of representative payee)

    

3. (3) 

   Choice 1 - your well-being.

   Choice 2 - her well-being.

   Choice 3 - his well-being.

    

4. (4) 

   (Name of representative payee)

    

5. (5) 

   Choice 1 - you are due

   Choice 2 - (Name of recipient) is due

    

6. (6) 

   Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

1. 1610. 

   Situation Where Used:

Notice to recipient determined to be DA and A that representative payee has been selected. For cases in E01.

 

The medical evidence has been reviewed and it has been determined that     (1)    disabled. Because    (2)    contributes to the finding of    (3)    disability, the law requires that    (4)    receive payments through another person or agency. Based on information we have received, we have determined that any Supplemental Security Income payments which may be due in the future for    (5)    will be paid to    (6)    who is interested in or concerned with    (7)    This representative has agreed to receive and manage these payments for    (8)    .

 

1. (1) 

   Choice 1 - you are

   Choice 2 - (Name of disabled person) is

    

2. (2) 

   Choice 1 - alcoholism

   Choice 2 - drug addiction

   Choice 3 - alcoholism and drug addiction

    

3. (3) 

   Choice 1 - your

   Choice 2 - her

   Choice 3 - his

    

4. (4) 

   Choice 1 - you

   Choice 2 - she

   Choice 3 - he

    

5. (5) 

   Choice 1 - you

   Choice 2 - (Name of disabled person)

    

6. (6) 

   (Name of representative payee selected)

    

7. (7) 

   Choice 1 - your well-being.

   Choice 2 - her well-being.

   Choice 3 - his well-being.

    

8. (8) 

   Choice 1 - your use and benefit

   Choice 2 - her use and benefit

   Choice 3 - his use and benefit

   Choice 4 - the use and benefit of (Name of disabled person)

    

1. 1618. 

   Situation Where Used:

Recipient determined to be DA and A.

 

NOTE: OBSOLETE—(Replaced by 1621, January 31, 1987.)

 

We need information from you which will assist us in selecting a representative payee to receive    (1)    . Please contact your Social Security office within 15 days to arrange for an appointment. If you contact us, please have this notice available so that you may refer to it. If you believe the determination that    (2)    to the finding that you are disabled is not correct, you may request reconsideration as explained on the reverse of this letter.

 

1. (1) 

   Choice 1 - your Supplemental Security Income payments on your behalf

   Choice 2 - any Supplemental Security Income payments on your behalf that might be due in the future

    

2. (2) 

   Choice 1 - drug addiction contributes

   Choice 2 - alcoholism contributes

   Choice 3 - drug addiction and alcoholism contribute

    

1. 1621. 

   Situation Where Used:

Recipient determined to be DA and A.

 

We need information from you which will assist us in selecting a representative payee to receive    (1)    . Please contact your Social Security office within 15 days to arrange for an appointment. If you contact us, please have this notice available so that you may refer to it. If you believe the determination that    (2)    to the finding that you are disabled is not correct, you may request reconsideration as explained below.

 

1. (1) 

   Choice 1 - your Supplemental Security Income Income payments on your behalf

   Choice 2 - any Supplemental Security Income payments on your behalf that might be due in the future

    

2. (2) 

   Choice 1 - drug addiction contributes

   Choice 2 - alcoholism contributes

   Choice 3 - drug addiction and alcoholism contribute

    

1. 2001. 

   Situation Where Used:

Notice to representative payee that recipient who had been in payment status died.

 

NOTE: (Replaced 2293 and 2303, January 31, 1987.)

 

We learned recently that    (1)    , the person for whom you were receiving Supplemental Security Income payments, died    (2)    . In this letter we want to let you know what to do if you have any SSI money that belongs to    (3)    .

 

1. (1) 

   (Recipient's Name)

    

2. (2) 

   (Month/Day/Year)

    

3. (3) 

   (Recipient's Name)

    

1. 2290. 

   Situation Where Used:

Notice to recipient who becomes own payee.

 

We have decided that your Supplemental Security Income payments will be paid directly to you.

 

1. 2291. 

   Situation Where Used:

Notice to legally competent recipient that payments are suspended pending selection of a new payee.

 

Our records show that the representative payee    (1)    on your behalf is no longer acting as your representative payee.    (2)    As soon as we can determine the proper representative payee to    (3)    , we will notify you.    (4)   

 

1. (1) 

   Choice 1 - receiving payment

   Choice 2 - acting

    

2. (2) 

   Choice 1 - Accordingly, we will withhold further payment beginning (Month /Year) until another representative payee has been selected to receive payment on your behalf.

   Choice 2 - Null

    

3. (3) 

   Choice 1 - receive your benefits

   Choice 2 - act on your behalf

    

4. (4) 

   Choice 1 - Please let us know if you want to receive your own payments while we are making this determination.

   Choice 2 - Null

    

1. 2292. 

   Situation Where Used:

Notice to former payee regarding the selection of a new payee.

 

After considering all the information available, we have decided that Supplemental Security Income payments for    (1)    will be paid    (2)    .

 

1. (1) 

   Choice 1 - (Name of Recipient)

    

2. (2) 

   Choice 1 - to someone else

   Choice 2 - directly to her

   Choice 3 - directly to him

    

1. 2294. 

   Situation Where Used:

Notice to recipient who is own payee or to new representative payee. No payment due.

 

However, no payment can be made at this time.

 

1. 2298. 

   Situation Where Used:

Notice to representative payee after death of recipient.

 

NOTE: (Replaced 2299, January 31, 1987.)

 

If you Still Have Some of  (1)  SSI

All unused payments for this recipient plus accrued interest belong to     (2)    estate and should be turned over to the legal representative. If there is no legal representative, the fund should be disposed of in accordance with State law.

 

Uncashed Checks Should Be Returned

Uncashed checks should be returned to the Treasury Department, Bureau of Accounts, Division of Disbursement, as shown on the check envelope. If the check is for the month of death or earlier, get in touch with any Social Security office to see if the check may be reissued. If a check for any month after the month of death has been cashed, please make repayment in the amount of the    (3)    . Payments made to a financial institution after the month of death must also be returned.

 

1. (1) 

   Choice 1 - (Recipients Name)'s

   Choice 2 - (Recipients Name)'

    

2. (2) 

   Choice 1 - her

   Choice 2 - his

    

3. (3) 

   Choice 1 - check

   Choice 2 - checks

    

1. 2300. 

   Situation Where Used:

Notice to recipient in payment status that checks will not be sent pending selection of a representative payee. Recipient newly determined to be a drug addict or alcoholic.

 

We will withhold further payments beginning    (1)    until someone has been selected to receive payments on your behalf. We will notify you as soon as we can determine the proper person to receive your payments.

 

1. (1) 

   (Month/Day/Year)

    

1. 2301. 

   Situation Where Used:

Notice to newly selected representative payee.

 

We have decided that Supplemental Security Income payments for    (1)    will be sent to you. By regulation, all payments are to be used for    (2)    well-being and benefit. As representative payee for this individual, you have certain reporting responsibilities.

 

1. (1) 

   (Recipient's Name)

    

2. (2) 

   Choice 1 - her

   Choice 2 - his

    

1. 2302. 

   Situation Where Used:

Notice to new representative payee.

 

We have decided that any Supplemental Security Income payments which may be due in the future for    (1)    will be sent to you. By regulation, all payments are to be used for    (2)    well-being and benefit.

 

1. (1) 

   (Recipient's Name)

    

2. (2) 

   Choice 1 - her

   Choice 2 - his

    

1. 2489. 

   Situation Where Used:

Notice to recipient who has a representative payee.

 

This information is also being sent to    (1)    .

 

1. (1) 

   Choice 1 - your representative payee

   Choice 2 - (Name of recipient)

    

References:

Manual representative payee noticeswhich the field office must send, NL 00703.821-NL 00703.828