Completion of SSA-11-BK Form

Before applying to be appointed as the child’s representative payee for Social Security Administration (SSA) benefits, the county must send a written notice of the intent to be appointed to the child’s attorney and parents or legal guardians.

The Request To Be Selected as Payee form (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 receives Retirement, Survivor, Disability Insurance (RSDI or Supplemental Security Income (SSI.

The SSA-11-BK must be completed when the youth is approaching 16 or older but under 21. The youth must have a new medical and financial determination when they become 18. The process begins six months before the youth’s 18th birthday but is evaluated by SSA when the youth reaches 18. The Analyst is responsible for completing the application at least 30 days before the youth’s 18th birthday when the youth is already eligible for SSI benefits. If there is no SSI application, the application must begin 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 Extended Foster Care (EFC) program as an NMD, the assigned FC EW and SW/PO must begin 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 Analyst for completion. It is the Analyst's and SW/PO's responsibility to inform the NMD of becoming their own payee or allowing the county to serve as the payee during the time the NMD is participating in EFC. When the NMD elects to
receive benefits directly, the Analyst must inform the assigned SW/PO and advise the NMD that any benefits received directly will impact their eligibility for FC benefits (Youth Over 18 Years Old Becoming Their Own Payee for SSA or SSI Benefits).

FC Eligibility Worker (EW) Responsibilities: IEVS and MEDS with SSI/RSDI Information

FC EWs must review Income and Employment Verification System (IEVS reports at initial intake. Results must always be documented in a CalSAWS Journal and referred to the Analyst 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.

FC EWs must review the Medi-Cal Eligibility Data System (MEDS) at intake and redetermination 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 Analyst and the assigned SW/PO. The FC EW must take appropriate action to ensure 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 form (SSA-11-BK) form according to the instructions. Directions are found in the EW Tools Folder/SSI Advocacy Program/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 Analyst with a copy of the latest court report.
Sends copy of the SSA-11-BK to Imaging.
Due to confidentiality issues, refer all calls from the Social Security Administration (SSA) about the child’s/youth’s placement or other questions about the information on the SSA-11-BK to the Analyst.

Analyst 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 the Social Security Administration (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 legal guardian (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 Analyst must:

Complete Referral To/From Social Security form (SCD 169)
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 SSA to suspend SSI benefits. The benefits remain suspended until the youth reaches the age of 16. Refer to “Screening."
Upon receipt of confirmation that the SSA has suspended benefits, the completed SCD 169 is returned to the Analyst and copy is sent to Imaging.
Requests the FC EW to complete a Request for Online Transaction form (SCD 1296) for the MEDS Terminal Operator (MTO to change the aid code from 60 to 42. A copy of the request must be sent to Imaging.

Additional SSA Forms

Below is an abbreviated list of forms used documents by the Analyst, 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 Analyst 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 Analyst 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.