SSA-4547 - Current

Form SSA-4547 (03-2024)
Social Security Administration

Page 1 of 2
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 (03-2024)

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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. Furnishing us this information is
voluntary. However, failing to provide all or part of the information may prevent us from selecting the representative payee(s) you
designate to act on your behalf.
We will use the information to maintain your advance designation of a representative payee(s). We may also share your
information for the following purposes, called routine uses:
• We may disclose information to contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs. We contemplate disclosing
information under this routine use only in situations in which SSA may enter a contractual or similar agreement with a
third party to assist in accomplishing an agency function relating to this system of records; and
• To third party contacts in situations where the party to be contacted has, or is expected to have, information relating to
the individual's capability to manage his or her affairs or his or her eligibility for or entitlement to benefits under the Social
Security program.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0089, entitled Claims Folders
System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784. Additional information, and a full listing of all
of our SORNs, is available on our website at www.ssa.gov/privacy.

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.