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:
               
                
               
                  - 
                     
                        • 
                           the claimant DIES (special veterans entitlement ends the month after the claimant
                              dies);
                            
 
 
- 
                     
                        • 
                           the claimant returns to the United States for a calendar month or longer; 
 
 
- 
                     
                        • 
                           the claimant moves or changes the place where he/she actually lives; 
 
 
- 
                     
                        • 
                           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;
                            
 
 
- 
                     
                        • 
                           the claimant is or has been deported or removed from U.S.; 
 
 
- 
                     
                        • 
                           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;
                            
 
 
- 
                     
                        • 
                           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
               
                  - 
                     
                  
- 
                     
                        • 
                           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:
               
                  - 
                     
                        • 
                           payments must be used for the claimant's current needs or saved if not currently needed; 
 
 
- 
                     
                        • 
                           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;
                            
 
 
- 
                     
                        • 
                           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;
                            
 
 
- 
                     
                        • 
                           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 | 
                     
                     
                        
                        
                           
                           |   TELEPHONE NUMBER(S) TO CALL IF YOU HAVE A
 QUESTION OR SOMETHING
 TO REPORT
 | BEFORE YOU RECEIVE A DECISION NOTICE
   | SSA OFFICE | DATE REQUEST RECEIVED | 
                        
                           
                           | AFTER YOU RECEIVE A DECISION NOTICE
 | 
                        
                           
                           | RECEIPT FOR YOUR REQUEST | 
                        
                           
                           | 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
                               | 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. | 
                        
                           
                           | BENEFICIARY | SOCIAL SECURITY CLAIM NUMBER | 
                        
                           
                           |  |  | 
                        
                           
                           |  |  | 
                        
                           
                           |  |  | 
                        
                           
                           |  |  | 
                        
                           
                           |  |  | 
                        
                           
                           | 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 |