Organizational Payee
Become an Organizational Payee
Training for Organizational Payees
Guide for Organizational Representative Payees
Sample Payee Reporting Form
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? | Yes No | |
| 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: | ||