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Appendix C: Selected Forms
Pages 173-216

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From page 173...
... , 210 Agreement to Administer Benefits Under the Old Age Security Act and/or the Canada Pension Plan by a Private Trustee (SC ISP-3506) , 213 Agreement to Administer Benefits Under the Old Age Security Act and/or the Canada Pension Plan by an Agency or Institution (SC ISP-3507)
From page 174...
... Matching programs compare our records with records kept by other Federal, state or local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for Federally funded and administered benefit programs and for repayment of payments or delinquent debts under these programs.
From page 175...
... Matching programs compare our records with records kept by other Federal, state or local government agencies. Information from these matching programs can be used to establish or verify a person's eligibility for Federally funded and administered benefit programs and for repayment of payments or delinquent debts under these programs.
From page 177...
... Does the parent show interest in the child? YES NO Please explain.
From page 178...
... Enter the EIN of the institution INFORMATION ABOUT INDIVIDUALS APPLYING TO BE REPRESENTATIVE PAYEE 12. Enter: YOUR NAME DATE OF BIRTH SOCIAL SECURITY NUMBER ANY OTHER NAME YOU HAVE USED OTHER SSN'S YOU HAVE USED 13.
From page 179...
... • File an annual report of earnings if required. • Notify the Social Security Administration as soon as I/my organization can no longer act as representative payee or the claimant no longer needs a payee.
From page 180...
... . In addition to these events about the claimant, you must also notify us if: • YOU change your address; • YOU are convicted of a felony or any offense under State or Federal law which results in imprisonment for more than 1 year; • YOU have a UNSATISFIED FELONY WARRANT (or in jurisdictions that do not define crimes as felonies, a crime punishable by death or imprisonment exceeding 1 year)
From page 181...
... A complete list of routine uses for this information is available in our Privacy Act Systems of Records Notice entitled, Master Representative Payee File, 60-0222. Additional information regarding these and other systems of records notices are available on-line at www.socialsecurity.gov or at your local Social Security office.
From page 182...
... ; • the RESOURCES of the claimant or anyone in the claimant's household CHANGES (this includes when conserved funds reach over $2,000) ; • the claimant or anyone in the claimant's household MARRIES; • the marriage of the claimant or anyone in the claimant's household ends in DIVORCE or ANNULMENT; • the claimant SEPARATES from his/her spouse; • the claimant is confined to jail, prison, penal institution or correctional facility; • the claimant is confined to a public institution by court order in connection WITH A CRIME; • the claimant has an UNSATISFIED FELONY WARRANT (or in jurisdictions that do not define crimes as felonies, a crime punishable by death or imprisonment exceeding 1 year)
From page 183...
... A complete list of routine uses for this information is available in our Privacy Act Systems of Records Notice entitled, Master Representative Payee File, 60-0222. Additional information regarding these and other systems of records notices are available on-line at www.socialsecurity.gov or at your local Social Security office.
From page 184...
... raey 1 gnideecxe tnemnosirpmi ro htaed yb elbahsinup ni ro liam ,enohpelet yb stroper ruoy ekam nac uoY .RUCCO STNEVE EVOBA EHT FO YNA FI POTS YAM STIFENEB .S.U yna ro senippilihP eht ni eciffO lanoigeR sriaffA snareteV ,etalusnoC ,yssabmE .S.U yna tcatnoc nac uoY .nosrep SPECIAL BENEFITS FOR WORLD WAR II VETERANS Information for Representative Payees Who Receive Special Benefits for WW II Veterans .eciffO ytiruceS laicoS :REBMEMER ;dedeen yltnerruc ton fi devas ro sdeen tnerruc s'tnamialc eht rof desu eb tsum stnemyap • taht tnemyaprevo yna fo ro sdeen s'tnamialc eht rof desu ton stnemyap yna fo tnemyaper rof elbail dleh eb yam uoy • YOU MUST NOTIFY THE SOCIAL SECURITY ADMINISTRATION PROMPTLY IF ANY OF THE FOLLOWING ;tluaf ruoy ot eud derrucco woh fo sdrocer peek lliw uoY .noitartsinimdA ytiruceS laicoS eht yb deksa os nehw stifeneb rof tnuocca tsum uoy • EVENTS OCCUR AND PROMPTLY RETURN ANY PAYMENT TO WHICH THE CLAIMANT IS NOT ENTITLED: ;gnitnuocca tcerroc a htiw su edivorp nac uoy os tneps erew stifeneb regnol on tnamialc eht ro eeyap evitatneserper sa eunitnoc ot elbanu era uoy wonk uoy sa noos sa ,wonk su tel ot • .eeyap a sdeen • the claimant DIES (special veterans entitlement ends the month after the claimant dies) ; • the claimant returns to the United States for a calendar month or longer; • the claimant moves or changes the place where he/she actually lives; • the claimant receives a pension, annuity or other recurring payment (includes workers' compensation, veterans benefits or disability benefits)
From page 185...
... A complete list of routine uses for this information is available in our Privacy Act Systems of Records Notice entitled, Master Representative Payee File, 60-0222. Additional information regarding these and other systems of records notices are available on-line at www.socialsecurity.gov or at your local Social Security office.
From page 186...
... Function Report - Adult Form SSA-3373-BK HOW TO COMPLETE THIS FORM The information that you give us on this form will be used by the office that makes the disability decision on your disability claim. You can help them by completing as much of the form as you can.
From page 187...
... These notices, additional information regarding this form, and information regarding our systems and programs, are available on line at www.socialsecurity.gov or at any local Social Security office. Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C.
From page 188...
... (Check one.) House Apartment Boarding House Nursing Home Shelter Group Home Other (What?
From page 189...
... 11. Do the illnesses, injuries, or conditions affect your sleep?
From page 190...
... 190 FINANCIAL CAPABILITY DETERMINATION b. Do you need any special reminders to take care of personal Yes No needs and grooming?
From page 191...
... APPENDIX C 191 d. If you don't do house or yard work, explain why not.
From page 192...
... If "YES," explain how the ability to handle money has changed.
From page 193...
... a. Check any of the following items that your illnesses, injuries, or conditions affect: Lifting Walking Stair Climbing Understanding Squatting Sitting Seeing Following Instructions Bending Kneeling Memory Using Hands Standing Talking Completing Tasks Getting Along With Others Reaching Hearing Concentration Please explain how your illnesses, injuries, or conditions affect each of the items you checked.
From page 194...
... (Check all that apply.) Crutches Cane Hearing Aid Walker Brace/Splint Glasses/Contact Lenses Wheelchair Artificial Limb Artificial Voice Box Other (Explain)
From page 195...
... Email address (optional) City State ZIP Code Form SSA-3373-BK (01-2013)
From page 196...
... You can help by completing as much of the form as you can. When a question refers to the "disabled person," it refers to the person who is applying for or receiving disability benefits.
From page 197...
... These notices, additional information regarding our programs and systems, are available online at www.socialsecurity.gov or at any local Social Security office. Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C.
From page 198...
... (Check one.) House Apartment Boarding House Nursing Home Shelter Group Home Other (What?
From page 199...
... a. Explain how the illnesses, injuries, or conditions affect this person's ability to: Dress Bathe Care for hair Shave Feed self Use the toilet Other Form SSA-3380-BK (12-2009)
From page 200...
... 200 FINANCIAL CAPABILITY DETERMINATION b. Does he/she need any special reminders to take care of Yes No personal needs and grooming?
From page 201...
... APPENDIX C 201 d. If the disabled person doesn't do house or yard work, explain why not.
From page 202...
... Yes No If "YES," explain how the ability to handle money has changed.
From page 203...
... a. Check any of the following items the disabled person's illnesses, injuries, or conditions affect: Lifting Walking Stair Climbing Understanding Squatting Sitting Seeing Following Instructions Bending Kneeling Memory Using Hands Standing Talking Completing Tasks Getting Along with Others Reaching Hearing Concentration Please explain how his/her illnesses, injuries, or conditions affect each of the items you checked.
From page 204...
... (Check all that apply.) Crutches Cane Hearing Aid Walker Brace/Splint Glasses/Contact Lenses Wheelchair Artificial Limb Artificial Voice Box Other (Explain)
From page 205...
... Email address (optional) City State Zip Code Form SSA-3380-BK (12-2009)
From page 206...
... Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing time needed, to the Office of Personnel Management (OPM) Retirement Services Publications Team (3206-0140)
From page 207...
... Box 45 Boyers, PA 16017-0045 Date of this letter File reference • Name of annuitant Claim number Representative Payee Application The Office of Personnel Management (OPM) has received information indicating that the above-named annuitant may not be capable of handling his or her benefits under the Civil Service Retirement System or the Federal Employees Retirement System.
From page 208...
... 17. Explain below how, if you are selected representative payee, you will use the annuity payments to meet the needs and provide for the well-being of the annuitant.
From page 209...
... This information may be shared and is subject to per response to complete, including the time for verification via paper, electronic media, or through the use of computer matching programs, with reviewing instructions, getting the needed data, and national, state, local, or other charitable or social security administrative agencies to determine reviewing the completed form. Send comments and issue benefits under their programs, to obtain information necessary for determination or regarding our estimate or any other aspect of this form, continuation of benefits under this program, or to report income for tax purposes.
From page 210...
... Comments Service Canada delivers Employment and Social Development Canada programs and services for the Government of Canada.
From page 211...
... Membership/Registration Number: Note: If you make a false or misleading statement, you may be subject to an administrative monetary penalty and interest, if any, under the Canada Pension Plan or the Old Age Security Act, or may be charged with an offence. Any benefits you received or obtained to which there was no entitlement would have to be repaid.
From page 212...
... John's NL A1A 2Y5 PO Box 5100 Station D CANADA Scarborough ON M1R 5C8 CANADA PRINCE EDWARD ISLAND ONTARIO Service Canada For postal codes beginning with "K or P" PO Box 8000 Station Central Service Canada Charlottetown PE C1A 8K1 PO Box 2013 Station Main CANADA Timmins ON P4N 8C8 CANADA NOVA SCOTIA Service Canada MANITOBA AND SASKATCHEWAN PO Box 1687 Station Central Service Canada Halifax NS B3J 3J4 PO Box 818 Station Main CANADA Winnipeg MB R3C 2N4 CANADA NEW BRUNSWICK ALBERTA / NORTHWEST TERRITORIES Service Canada AND NUNAVUT PO Box 250 Station A Service Canada Fredericton NB E3B 4Z6 PO Box 2710 Station Main CANADA Edmonton AB T5J 2G4 CANADA QUEBEC BRITISH COLUMBIA AND YUKON Service Canada Service Canada PO Box 1816 Station Terminus PO Box 1177 Station CSC Quebec QC G1K 7L5 Victoria BC V8W 2V2 CANADA CANADA Disponible en français SC ISP-3501-OAS (2014-01-24)
From page 213...
... to notify Employment and Social Development Canada if the beneficiary changes address, becomes absent from Canada, dies, ceases to be incapable of managing his/her own affairs or if the trusteeship ends. And to provide any other information or evidence, and to do anything that the Old Age Security Act and/or the Canada Pension Plan or their Regulations would require from the beneficiary; and 4.
From page 214...
... to notify Employment and Social Development Canada if the beneficiary changes address, becomes absent from Canada, dies or ceases to be incapable of managing his/her own affairs, or if the trusteeship ends; and to provide any other information or evidence, and to do anything that the Old Age Security Act and/or the Canada Pension Plan or the Regulations would require from the beneficiary; and 4. to return, if the beneficiary should die, all his/her Old Age Security and/or Canada Pension Plan benefit payments which may be made after the month of death, and to reimburse Her Majesty the Queen in Right of Canada for any loss sustained by her through the receipt of such payments.
From page 215...
... Yes No NOTE: If you make a false or misleading statement, you may be subject to an administrative monetary penalty and interest, if any, under the Canada Pension Plan or the Old Age Security Act, or may be charged with an offence. Any benefits you received or obtained to which there was no entitlement would have to be repaid.


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