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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Appendix C

Selected Forms

U.S. SOCIAL SECURITY ADMINISTRATION

Physician’s/Medical Officer’s Statement of Patient’s Capability to Manage Benefits (Form SSA-787), 174

Request to Be Selected as Payee (Form SSA-11-BK), 176

Adult Function Report Form (Form SSA-3373-BK), 186

Adult Third Party Function Report Form (Form SSA-3380-BK), 196

U.S. OFFICE OF PERSONNEL MANAGEMENT

Information Necessary for a Competency Determination (RI 30-3), 206

Representative Payee Application (RI 20-7), 207

SERVICE CANADA

Certificate of Incapability (SC ISP-3505), 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), 214

Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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Suggested Citation:"Appendix C: Selected Forms." National Academies of Sciences, Engineering, and Medicine. 2016. Informing Social Security's Process for Financial Capability Determination. Washington, DC: The National Academies Press. doi: 10.17226/21922.
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The U.S. Social Security Administration (SSA) provides benefits to disabled adults and children, offering vital financial support to more than 19 million disabled Americans. Of that group, approximately 5.5 million have been deemed – by virtue of youth or mental or physical impairment - incapable of managing or directing the management of their benefits. Hence, a representative payee has been appointed to receive and disburse SSA payments for these beneficiaries to ensure that their basic needs for shelter, food, and clothing are met. Periodically, however, concerns have been expressed about the accuracy of the process by which SSA determines whether beneficiaries are capable of managing their benefits, with some evidence suggesting that underdetection of incapable recipients may be a particular problem.

The importance of creating as accurate a process as possible for incapability determinations is underscored by the consequences of incorrectly identifying recipients either as incapable when they can manage their benefits or as capable when they cannot. Failure to identify beneficiaries who are incapable of managing their funds means abandoning a vulnerable population to potential homelessness, hunger, and disease.

Informing Social Security’s Process for Financial Capability Determination considers capability determination processes used by other similar benefit programs, abilities required to manage, and direct the management of, benefits, and effective methods and measures for assessing capability. This report evaluates SSA’s capability determination process for adult beneficiaries and provides recommendations for improving the accuracy and efficiency of the agency’s policy and procedures for making these determinations.

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