TN 51 (11-06)

(See GN 00506.010B. for application requirements.)

Document Identifier for Word Processor: E3942

A. Exhibit Letter

Before you may collect a fee for representative payee services, you must complete and submit a form SSA-445, Application to Collect a Fee for Payee Services, requesting authorization from the local Social Security office, and SSA must approve your application. Your application must include all the information and documents listed below and be signed by the Director of your organization or by another individual who can legally act for the organization.

Information You Need To Give Us

The following information about your organization is required as part of the fee for service application process:

• Employer Identification Number

• The organization’s mission statement

• Service area (the neighborhoods, cities, counties served)

• Statement showing whether the organization currently charges any of the beneficiaries for its services.

• A list of the names, Social Security numbers, and residence addresses of beneficiaries for whom the organization is currently providing representative payee services.

Documents You Need to Give Us If You Are Not a State or Local Government Agency

Enclose the following documents with the request:

• A copy of the letter from the Internal Revenue Service granting tax-exempt status under section 501(C) of the Internal Revenue Code.

• A copy of the organization's current bonding agreement with an insurance company (The type of bond requested is the one that guarantees payment to the organization or the Social Security Administration for unforeseen financial loss through the actions of an employee.)

• A copy of the organization's current State license, certificate or notice that allows it to provide service within the State.

B. Requesting Instructions

The FO will send this exhibit as an enclosure to the cover letter to organizations inquiring about payment for representative payee services (NL 00703.940).

C. Typing Instructions

The FO will send this notice using plain bond paper.