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 diedDate 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: