TN 7 (09-01)

DEDICATED ACCOUNT USE OF FUNDS STATEMENT

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^{Name (Child)                                                                                                     Social Security Number:}

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^{Name (Representative Payee):}

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I am the representative payee for the disabled child under the age of 18 identified above. I understand that the law says I have to open a separate account at a financial institution for certain, large SSI checks that I may get on behalf of the child. This account is called a “dedicated” account because I can only use money in this account to pay for items and services as described below.

I also understand funds in the dedicated account do not count in determining the child's eligibility for SSI payments but if I deposit unauthorized funds into the dedicated account the child's eligibility for SSI may be affected.

1. I May Use Money From The Dedicated Account For

   • Medical treatment and education or job skills training; or

   • Items and services related to the child's impairment that benefit the child such as:

     • Personal needs assistance (for example, in-home nursing care);

     • Special equipment;

     • Housing modifications;

     • Therapy or rehabilitation; or

   • Other items or services related to the child's impairment like legal fees incurred by the child in establishing a claim for disabled child's benefits.

   NOTE: If you are uncertain as to whether or not an expenditure is allowed, you should seek SSA's approval before making the expenditure.

2. I May Not Use Money From The Dedicated Account For

   • Basic maintenance costs such as for food, housing, clothing and personal items which are not related to the child's impairment;

   • Repayment of an SSI overpayment; and

   • Any other items not listed above that are not related to the child's impairment.

   NOTE: In emergency situations, the Social Security Administration (SSA) may approve use of dedicated account funds for basic living expenses to prevent the child from becoming homeless or malnourished.

3. If You Have Any Questions

   If you have any questions whether the money from the dedicated account may be used for a specific item or service, please call, write or visit your local Social Security Office.

Please read the following information carefully, before signing this statement:

The restrictions on the use of dedicated account funds will continue to apply until all account funds are spent or the child's eligibility for benefits terminates.

I understand how dedicated account funds can and cannot be used and I agree to:

1. Use the money in the dedicated account only for items and services approved under the law or by SSA;

2. Use the regular monthly SSI benefit payment for the child's basic needs for food, housing, clothing, and personal items;

3. Keep records and receipts of how money from the dedicated account was used and any deposits made into the account for at least 2 years;

4. Complete the Representative Payee Report Of Benefits And Dedicated Account (SSA-6233-BK) on the use of dedicated account funds;

5. Provide SSA with an explanation of any item or service purchased if requested;

6. Use my own funds to repay any money to SSA that I knowingly used from this dedicated account for anything other than the items and services approved under the law or by SSA; and

7. Return all funds remaining in the dedicated account to SSA if I stop serving as payee.

^SIGNATURE

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