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E Phone - (713) 363-2391 Intake Fax Please fax referral to number listed above REP Payee Case Manager Assigned (assigned by Intake Staff) Referring Agency ( ) Hamilton, Rodney ( ) Nwokobia, Alfred Referring Personnel Client Referred: Phone# (Cell and Office) (Last Name, First Name, M. I.) Address: Phone# City, State, Zip Code: Gender: Male ( ) Female ( ) Age: Marital Status: Single ( ) Living Status: Own ( ) DOB: Married ( ) Rent ( ) SS#: Mother s Maiden Name: Divorced (.

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Social Security's Representative Payment Program provides benefit payment management for our beneficiaries who are incapable of managing their Social Security or Supplemental Security Income (SSI) payments.

Your representative payee must use your benefits to pay for your needs. These could include payment for food, shelter, clothes, medical care and personal comfort items. Also, your representative payee must tell SSA of events that could change the amount of, or affect your right to receive, benefits.

You may receive a Representative Payee Report form for you to account for the Social Security or SSI benefits received or we may select you for a representative payee review. The review is to determine if you have performed the following duties: Managed funds so the beneficiary(ies) have no unmet current needs.

To complete an SSA 11-BK, you will need to provide the following information: Name of the number holder. Social security number. Name of the person(s) for whom you are filing (claimant) Claimant's social security number. Indication if you are the claimant and what your benefits paid directly to you.

Representative payees can fill out the form and return it to Social Security by mail, or conveniently file it online at .ssa.gov/myaccount/rep-payee.html. Organizational representative payees are able to complete their Representative Payee Report online by using Business Services Online.

How to complete an SSA 795 (Step by Step) Name. Social security number. Name of person making statement. Relationship to wage earner, self-employed person, or SSI claimant. Certified statement that is for the Social Security Administration. Signature of person making statement. Date. Telephone number.

You must complete form SSA-11 (Request to be selected as payee) and show us documents to prove your identity. You will need to provide your social security number, or if you represent an organization, the organization's employer identification number.

0:39 2:25 How to Fill SSA-561-U2 Request for Reconsideration with YouTube Start of suggested clip End of suggested clip The next block requires. Contact information of the claimant. And their representative.MoreThe next block requires. Contact information of the claimant. And their representative.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232