Representative Payee Confidential Complaint of Misuse of Benefits/ Financial Exploitation Form

Please note: This is a complaint to Disability Rights Connecticut and will assist us in potential investigations of rights violations. Although DRCT cannot investigate all complaints, the information may be used to identify trends or systemic issues. The link for this form is: https://www.disrightsct.org/rep-payee-confidential-complaint-of-misuse-of-benefits-or-financial-exploitation

This complaint is not a substitute to the Social Security Administration (SSA). For more information go to this website link: https://oig.ssa.gov/report/ on how to file a complaint with SSA.

The representative payee is a(n):

Individual

Business

Other

What is your complaint about this representative payee?

Full name of the representative payee:

First Name

Last Name

Address of the representative payee:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Representative payee email address (if they have one):

Phone number of representative payee:

(###)

###

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Witness(es) name and contact information:

How many people do you think are served by this representative payee?

Optional:

*Disability Rights Connecticut cannot follow up with you if you do not leave your name and email address. If you choose to share your name and contact information, we will keep it strictly confidential and use it only to get in contact with you if we need more information about your complaint or have an update for you on any steps we may take in response to your complaint.

First Name

Last Name

Email address:

Phone:

(###)

###

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