Completion of “Request To Be Selected As Payee” (SSA-11-BK) Form

The SSA-11-BK must be completed during the Intake process or during the Continuing process when the FC EW has verified the FC child or youth is in receipt of RSDI or SSI.

The SSA-11-BK must be completed when the youth is approaching 16.5 or older but under 21. The youth must have a new medical and financial determination when they become 18. The process begins three months prior to the youth’s 18th birthday but is evaluated by SSA when the youth reaches 18. The SWC is responsible for completing the application at least 30 days prior to the youth’s 18th birthday when the youth is already eligible for SSI benefits. If there is no application for SSI the application must be start at least 90 days before the youth turns 18. The FC EW is not required to assist in the process.

When the youth is in the EFC program as a NMD, the assigned FC EW and SW/PO must begin the process of completing the SSA-11-BK when SSI benefits have not been approved. The FC EW begins completing the SSA-11-BK and forwards it to the SWC for completion. It is the SW/PO responsibility to inform the NMD regarding becoming their own payee or allowing the county to be the payee during the time the NMD is participating in EFC. When the NMD elects to
receive benefits directly, the SWC must inform the assigned SW/PO and advise the NMD that any benefits received directly will impact their eligibility for FC benefits (Youth Over the 18 Years Old Becoming Their Own Payee for SSA or SSI Benefits).

Foster Care Eligibility Worker Responsibilities:IEVS Reports/MEDS with SSI/RSDI Information

FC EWs must review IEVS reports on an ongoing basis. IEVS must be ran at initial intake and the annual RRR. Results must always be documented in a CalSAWS journal entry and referred to the SWC when completing the initial SSA-11-BK or when it is determined that a child or youth is under the supervision of DFCS or JPD and there is no open claim. [Refer to “Income Eligibility Verification System (IEVS),”] in the Common Place Handbook for details on requesting IEVS.

FC EWs must review the MEDS to verify if the FC child/youth is receiving SSI or RSDI benefits. When the FC EW determines the youth is receiving SSI benefits and the “FC SSI Approved” flag is not entered in CalSAWS, the FC EW must immediately notify the SWC and the assigned SW/PO. The FC EW must take the appropriate action to be sure the SSI income is counted to avoid any possible overpayments.

Requesting Representative Payee

When it is necessary to change the representative payee of a child’s RSDI or SSI to SCCSSA the FC EW must:

Begin the “Request To Be Selected As Payee” (SSA-11-BK) according to the instructions. Refer to Filling out the SSA-11-BK.

Note: A current SSA-11-BK is located at http://www.socialsecurity.gov/forms/ssa-11-bk.pdf. The SSA-11-BK is also completed when the FC youth is no longer eligible for foster care benefits because of age or the dismissal of dependency.

Forwards the completed SSA-11-BK to the SWC with a copy of the latest court report.
Sends copy of the SSA-11-BK to imaging.
Due to confidentiality issue refer all calls from Social Security pertaining to the child’s/youth’s placement or other questions about the information on the SSA-11-BK to the SWC.

Social Work Coordinator Responsibilities

Applies for RSDI/SSI when a child is potentially eligible.
Completes the SSA-11-BK when notified a court dependent child or youth is potentially eligible for benefits and there is no assigned FC EW.
Reviews the SSA-11-BK for complete and correct information. Updates or adds any additional information or documents that are required.
Obtains additional court documents from the child’s or youth’s SW/PO, as needed.
Forwards the SSA-11-BK and supporting documentation to SSA.
Responds to contacts from SSA which pertain to the child’s/youth’s placement and/or other questions regarding the application for representative payee status.
Blocks out all confidential information on the court documents.
Assists the youth or the LG in completing the SSA-11-BK when exiting FC due to age or no longer eligible for FC benefits or when the caregiver becomes a non-dependent LG.

When a Federal AFDC-FC case is receiving a grant that is higher than the SSI award, the SWC must:

Complete form SCD 169 “Referral To/From Social Security.”
Print the Search For Issuance window in CalSAWS for the past three (3) months and the CWS/CMS placement log.
Sends the request to the Social Security Administration to suspend SSI benefits. The benefits remain suspended until the youth reaches the age of 16.5 [Refer to “Screening,” page 35-27]]
Upon receipt of confirmation that the Social Security Administration has suspended benefits, the completed SCD 169 is returned to the SWC and copy is sent to imaging.
Requests the FC EW to complete a “Request for Online Action” (SCD 1296) for the MTO to change the aid code from 60 to 42. A copy of the request must be sent to imaging.

Filling out the SSA-11-BK

Follow these instructions when completing the SSA-11-BK:

For a LEGAL GUARDIAN WITHOUT DEPENDENCY (including Kin-GAP), contact the SWC to assist the LG with completing the SSA-11-BK.
One form per child.
Print using BLACK or BLUE ink
Any “white outs” of incorrect information must be initialled.

Item	Instruction
Top of Form	Indicate type of benefits the child is receiving: SSI RSDI, or RSDI and SSI
Name of the Number Holder	The information to be entered depends on type of benefits the child is receiving: SSI Only -- Enter the child’s name and SSN. RSDI Only -- Enter the wage earner’s name and SSN. RSDI and SSI -- Enter the child’s name and SSN.
Name and SSN of “claimant(s)”	Complete this section only when the child is receiving RSDI benefits. More than one child can be listed.
1.	Leave blank. Not used by our Agency.
2.	Always check “Claimant is a minor child.”
3.	Enter: Child is a dependent, or Child is a ward of the Juvenile Court.
4.	Check “By other means” and write in “Regular visits by SW (or PO).”
5.	Check “NO” unless the child has a court appointed legal guardian. If the child has a court appointed legal guardian, regardless of dependency status: Check “YES” and complete all requested information. Enter the date the court granted guardianship. Attach the letter of appointment to the SSA-11-BK.
6a.	Check “In a board and care facility” for all placements EXCEPT a medical facility. “Board and care” includes relative placements and guardians with dependency. For guardians with no dependency, contact the SWC for instructions.
6b.	In this section, it is important that the information clearly indicates that the child is in a Foster Care placement, especially when a child’s foster parent is a relative. NAME Enter the name of the foster parent or group home. RELATIONSHIP Enter one of the following: Foster parent (includes an FFA) Relative foster parent, or Group Home
6c.	Residence: Enter the address of the child’s actual place of residence, NOT the business address. Mailing: Enter DFCS, 373 West Julian Street, San Jose, CA 95110-2335 Telephone Number: Enter the phone number of the SSA/SSI SW Coordinator, including the area code.
6d.	Always check “NO.”
7a, b & c.	Enter confidential for the name, address and phone number of both parents, even if known. If the child is freed or the parent(s) are deceased, please indicate so.
7d.	Check: “YES” if it’s a Family Reunification or Family Maintenance case, and write “Parents are following the service plan.” “NO” if a child is in a permanent placement, and write “No requirement.”
8.	Complete this section only when the child is in a relative foster parent placement. Enter the name, address, phone number of the relative and the relative’s relationship to the child. DESCRIBE SUPPORT/INTEREST Enter “Foster parent.”
9a.	Check (a) and “Social Agency.” Leave the remainder of this section (b - e) blank.
10.	Always check “NO.”
11. a/b	Enter Social Service Agency. Enter Agency EIN: 94-6000533
12 - 18	Leave Blank
REMARKS:	Use this section to provide county payment directions: Please direct payments to: County of Santa Clara Social Services Agency Account number 4568-18-7903 Routing number 121-000-248 As well as additional clarifications and other pertinent information, as needed. For example: The application was delayed due to SSN problems, etc.
Signature of Applicant	Must be completed by the FC EW: Signature: FC EW’s name, position (EW), for DFCS. Date: The date that the application is completed. SSA/SSI SW Coordinator’s phone number, including the area code.
Mailing Address	County of Santa Clara Social Services Agency SSI/SSA Advocacy Program 333 West Julian Street San Jose, CA 95110-2335
Residence Address	Leave blank.

Additional SSA Forms

Below is an abbreviated list of forms used documents by the SWC, additional forms for services may also be required by SSA.

Authorization for Non-Medical Out-of-Home Care (SSP 22)

When a child placed in out-of-home care, the SWC must submit the SSP 22 along with the application. The SSP 22 is a request for a higher SSI rate and as a best practice must be submitted with all out-of-home placements. SSA is responsible for determining if the facility or caregiver meets the criteria for the NMOHC payment; however, the SWC should not delay submitting an initial application while awaiting for information necessary to submit the SSP 22.

Referral To/From Social Security (SCD 169)

The SCD 169 is used as communication tool between SCCSSA and SSA.

Sub-Payee Supplemental Disbursement Authorization or Action Request (SCD 1148)

This form is when requesting disbursement of fund retained in a CSP account.

SSI/SSA Advocacy Program for Foster Children & Non-minor Dependents (SCD 2432 AR and 2432 FC)

These documents are used to send to Accounts Receivable to disburse SSI/RSDI funds.

Protective Filing Date Memo to SSA (SCD 2455)

This document is used to protect a filing date for an SSI application.

Request to Accounts Receivable (SCD 2432 FC)

This document is used to request the disbursement of funds held in CSP account.

Application for Supplement Security Income (SSI) (SSA 8000-BK)

This form is used when applying for SSI benefits.

Application for Child’s Insurance Benefits (SSA-4)

This form is used when applying for RSDI benefits.