Transcription of REQUEST TO BE SELECTED AS PAYEE - ssdfacts.com
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REQUEST TO BE SELECTED AS PAYEE - ssdfacts.com
Does the claimant have a court-appointed legal guardian/conservator? YESNOIF YES, enter the legal guardian/conservator's:NAMEADDRESSPHONE NUMBERTITLEDATE OF APPOINTMENTThe name of the NUMBER HOLDERThe name of the PERSON(S) (if different from above) for whom you are filing (the"claimant(s)") REQUEST TOBE SELECTEDAS PAYEEForm ApprovedOMB No. 0960-0014 SOCIAL SECURITY ADMINISTRATIONTOE 250 PRINT IN INK:I REQUEST THAT THE SOCIAL SECURITY, SUPPLEMENTAL SECURITY INCOME, OR SPECIAL VETERANS BENEFITSFOR THE CLAIMANT(S) NAMED ABOVE BE PAID TO ME AS REPRESENTATIVE SSA-11-BK (08-2009)EF (08-2009)Destroy Prior EditionsPage 1 FOR SSA USE ONLYFOR SSA USE ONLYName or Bene. AND COUNTY CODE:SOCIAL SECURITY NUMBERSOCIAL 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 why you think the claimant is not able to handle his/her own benefits.
Does the claimant have a court-appointed legal guardian/conservator? YES NO IF YES, enter the legal guardian/conservator's: NAME ADDRESS PHONE NUMBER
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