Guide for Organizational Representative Payees

REPRESENTATIVE PAYEE REPORTING FORM
Social Security Administration		Date:
Fax No:
Beneficiary Name:		Social Security/Claim Number:
Please check which of the following apply:
	Beneficiary died	Date of Death Month Day Year
	Beneficiary left your care or custody	Month Day Year
Are there any conserved funds?		YesNo
IF YES, THE CONSERVED FUNDS MUST BE RETURNED TO SOCIAL SECURITY UNLESS THE BENEFICIARY DIED, AND IN THAT CASE, CONSERVED FUNDS MUST BE GIVEN TO THE LEGAL REPRESENTATIVE OF THE ESTATE OR OTHERWISE HANDLED ACCORDING TO STATE LAW.
Name and address of a relative or a close friend:
Please provide beneficiary's new address:
Beneficiary entered the hospital when?		Month/Day/Year (____/____/________) MM/DD/YYYY
Length of Stay if Known:
Signature and Title:		Date:
Name and Address of Organization:

REPRESENTATIVE PAYEE REPORTING FORM