Get SSA-11-BK 2017-2024

Use remarks if you need more space. Form SSA-11-BK 01-2014 EF 01-2014 Use 08-2009 EF 08-2009 edition until exhausted Page 1 NO 6. We estimate that it will take about 11 minutes to read the instructions gather the facts and answer the questions. Send only comments relating to our time estimate above to SSA 6401 Security Blvd Baltimore MD 21235-0001. 16. a Have you ever been convicted of a felony If YES What was the crime On what date were you convicted What was your sentence If imprisoned when were you released If probation was ordered when did/will your probation end b Have you ever been convicted of any offense under federal or state law which resulted in imprisonment for more than one year Page 3 17. Do you have any unsatisfied FELONY warrants or in jurisdictions that do not define crimes as felonies a crime punishable by death or imprisonment exceeding 1 year for your arrest If YES Date of Warrant State where warrant was issued REMARKS This space may be used for explaining any answers to the questions. If you need more space attach a separate sheet. PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING THIS FORM I/my organization Must use all payments made to me/my organization as the representative payee for the claimant s current needs or if not currently needed save them for his/her future needs. The individual s named below has been received and will be processed as quickly as possible. Always give us the claim number of the beneficiary when writing or telephoning about the claim. You should hear from us within days after you have given us all the information we requested. Some If you have any questions about this application we will claims may take longer if additional information is be glad to help you. needed. In the meantime if you change your address or if there is some other change that may affect the benefits payable BENEFICIARY Privacy Act Statement - Collection and Use of Personal Information Sections 205 a and 205 j of the Social Security Act as amended authorize us to collect this information. We will use the information you provide to determine if you are qualified to serve as a representative payee. Furnishing us this information is voluntary. However failing to provide all or part of the information could prevent us from making a determination to select you as a representative payee. Your request for Social Security benefits on behalf of The changes to be reported are listed on the reverse. the individual s named below has been received and will be processed as quickly as possible. Always give us the claim number of the beneficiary when writing or telephoning about the claim. You should hear from us within days after you have given us all the information we requested. Some If you have any questions about this application we will claims may take longer if additional information is be glad to help you. needed. In the meantime if you change your address or if there is some other change that may affect the benefits payable BENEFICIARY Privacy Act Statement - Collection and Use of Personal Information Sections 205 a and 205 j of the Social Security Act as amended authorize us to collect this information. We will use the information you provide to determine if you are qualified to serve as a representative payee. File an annual report of earnings if required. claimant no longer needs a payee. I declare under penalty of perjury that I have examined all the information on this form and on any accompanying statements or forms and it is true and correct to the best of my knowledge. DATE Month day year SIGNATURE OF APPLICANT Signature First name middle initial last name Write in ink may be contacted during the day Print Your Name Title if a representative or employee of an institution/organization Mailing Address Number and street Apt. No. P. O. Box or Rural Route City and State Zip Code Name of County Residence Address Number and street Apt. Comply with the conditions for reporting certain events listed on the attached sheets s which I/my organization will keep for my/my organization s records and for returning checks the claimant is not due. File an annual report of earnings if required. claimant no longer needs a payee. I declare under penalty of perjury that I have examined all the information on this form and on any accompanying statements or forms and it is true and correct to the best of my knowledge. DATE Month day year SIGNATURE OF APPLICANT Signature First name middle initial last name Write in ink may be contacted during the day Print Your Name Title if a representative or employee of an institution/organization Mailing Address Number and street Apt. If you need more space attach a separate sheet. PLEASE READ THE FOLLOWING INFORMATION CAREFULLY BEFORE SIGNING THIS FORM I/my organization Must use all payments made to me/my organization as the representative payee for the claimant s current needs or if not currently needed save them for his/her future needs. May be held liable for repayment if I/my organization misuse the payments or if I/my organization am/is at fault for any overpayment of benefits. May be punished under Federal law by fine imprisonment or both if I/my organization am/is found guilty of misuse of Use the payments for the claimant s current needs and save any currently unneeded benefits for future use.