SSA-4547 Advance Designation of Representative Payee

Form SSA-4547 (XX-XXXX)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0814

ADVANCE DESIGNATION OF REPRESENTATIVE PAYEE
IF YOU CURRENTLY HAVE A REPRESENTATIVE PAYEE, PLEASE DO NOT COMPLETE THIS FORM. CONTACT THE
NUMBER BELOW IF YOU HAVE QUESTIONS RELATED TO THE REPRESENTATIVE PAYEE PROGRAM.

ADVANCE DESIGNATION
As a Social Security beneficiary or applicant for benefits, you have the option to designate individuals, in order of priority, to serve
as your representative payee should you need one in the future. You must be at least 18 years of age or an emancipated minor
to make an advance designation. You can make updates or change the order of priority of your advance designee(s) at any time.
If you are a beneficiary, we will notify you annually of the individuals you have designated in advance as your potential
representative payee. If the time comes that you are not able to manage or direct the management of your benefits, we will follow
your order of priority to review and select your representative payee. If your advance designees are not able and willing to serve,
or do not meet SSA selection requirements, we will consider another representative payee to serve in your best interest.
NOTE: You may not designate an organization to serve as a representative payee.

WAIVER OF ADVANCE DESIGNATION OF REPRESENTATIVE PAYEE
I choose not to make an advance designation of a representative payee at this time. I understand that I may do so
later by notifying SSA. I can also use “my Social Security” account at https://www.ssa.gov/myaccount/ to provide
my advance designations, make necessary changes, or withdraw my advance designation.
PRINT YOUR NAME (First Name, Middle Initial, Last Name)

I am 18 years of age or older

Social Security Number

I am below 18 years of age, but I am an emancipated minor

Mailing Address (Number and Street, Apt. No., P.O. Box or Rural Route)

City

State/Country

Telephone (Area Code/Country Code and Number)

ZIP Code

Date (Month, Day, Year)

I am providing in priority order the name(s) and information of individuals below whom I want to designate in
advance to be my representative payee, should I need one in the future.
Order of Priority

Full Name of Designee
(ex: John A. Doe, Jr.)

Telephone Number
(999) 999-9999 Ext-99999
(Domestic or Foreign)

Relationship (optional)
(Spouse, parent, friend, etc.)

1
2
3
WITHDRAWAL:
I am withdrawing all of my previously provided advance designations.
THIS REPLACES ANY PREVIOUS ADVANCE DESIGNATION(S) ON FILE.
SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
Visit https://www.ssa.gov/locator to find SSA offices by zip code, and services outside the United States. SSA offices
are also listed under U.S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213. If you are deaf or hard of hearing, you may call our TTY Number, 1-800-325-0778.

Form SSA-4547 (XX-XXXX)

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EXPLANATION OF TERMS
WHAT IS A REPRESENTATIVE PAYEE
A representative payee is a third party who manages a beneficiary's SSA benefits to meet the beneficiary's current and
foreseeable needs. The representative payee has a strong and continuing interest in the beneficiary's well-being and must be
willing and able to serve.
WHO NEEDS A REPRESENTATIVE PAYEE
When SSA determines that a beneficiary is unable to manage or direct the management of his/her own benefits because of a
mental or physical condition, we appoint a representative payee to receive and manage the benefits on the beneficiary's behalf.

PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Section 205(j) of the Social Security Act, as amended, allows us to collect this information, which we will use to maintain and
update your advance designation of a representative payee. Providing this information is voluntary, but not providing all or part of
the information may prevent us from selecting the representative payee(s) you designate to act on your behalf. As law permits,
we may use and share the information you submit, including with other Federal, State, and local agencies, contractors,
employers, and others, as outlined in the routine uses within System of Records Notice (SORN) 60-0089, available at
www.ssa.gov/privacy. The information you submit may also be used in computer matching programs to establish or verify
eligibility for Federal benefit programs and to recoup debts under these programs.

PAPERWORK REDUCTION ACT STATEMENT - This information collection meets the requirements of 44 U.S.C. § 3507, as
amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a
valid Office of Management and Budget control number. We estimate that it will take about 6 minutes to read the instructions,
gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. You can find your local Social Security office through SSA's website at www.socialsecurity.gov.
Offices are also listed under U. S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.