Transcription of REQUEST TO BE SELECTED AS PAYEE
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Example: air traffic controller
REQUEST TO BE SELECTED AS PAYEE
Form SSA-11-BK (01-2014) EF (01-2014) Use (08-2009) EF (08-2009) edition until exhaustedSOCIAL SECURITY ADMINISTRATIONREQUEST TO BE SELECTED AS PAYEEForm Approved OMB No. 0960-0014 Page 1 TOE 250 FOR SSA USE ONLYName or Bene. of OFFICE CODESTATE AND COUNTY CODEPRINT IN INK:The name of the NUMBER HOLDERSOCIAL SECURITY NUMBERThe name of the PERSON(S) (if different from above) for whom you are filing (the "claimant(s)")SOCIAL SECURITY NUMBER(S)Answer item 1 ONLY if you are the claimant and want your benefits paid directly to REQUEST that I be paid HEREand answer only items 3, 5, 6, and 8 before signing the form on page REQUEST THAT THE SOCIAL SECURITY, SUPPLEMENTAL SECURITY INCOME, OR SPECIAL VETERANS BENEFITS FOR THE CLAIMANT(S)
Form SSA-11-BK (01-2014) EF (01-2014) Use (08-2009) EF (08-2009) edition until exhausted SOCIAL SECURITY ADMINISTRATION REQUEST TO BE SELECTED AS
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