Advance Designation of Representative Payee (Internet Version - iClaim)

ADVANCE DESIGNATION OF REPRESENTATIVE PAYEE
ANNUAL NOTICE
SSA NOTICE CLEARANCE PACKAGE

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Table of Contents

Contents
Section 1 ....................................................................................................................................................... 3
BACKGROUND .................................................................................................................. 3
Section 2 ....................................................................................................................................................... 5
ADVANCE DESIGNATION OF REPRESENTATIVE PAYEE ANNUAL NOTICE . 5
Section 3 ....................................................................................................................................................... 8
ADVANCE DESIGNATION OF REPRESENTATIVE PAYEE
ANNUAL NOTICE ................................................................................................................................. 8
*F1 FO Address ................................................................................................................................. 10
*F2 Date ............................................................................................................................................. 10
*F3 BNC# .......................................................................................................................................... 10
*F4 BENEFICIARY NAME ............................................................................................................. 10
*F5 Beneficiary Address .................................................................................................................... 10
*F6: 001 Name of Designee/002 Name of Designee/003 Name of Designee ................................... 10
*F7: 001 Designee Phone Number/002 Designee Phone Number/003 Designee Phone Number ..... 10
*F8: 001 Relationship/002 Relationship/003 Relationship ................................................................ 10

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Section 1
BACKGROUND

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BACKGROUND
On April 13, 2018, the President signed H.R. 4547, “The Strengthening Protections for Social
Security Beneficiaries Act of 2018” into law (P.L. 115-165). Section 201 of the law allows
applicants and beneficiaries to designate individuals to serve as a representative payee should
they need one in the future and requires the Social Security Administration (SSA) to consider for
selection the designated individual (with certain exceptions). SSA will provide this option to
beneficiaries receiving Title 2, Title 8, and Title 16 benefits and applicants when they apply for
benefits. Only competent adults 18 years and over, and emancipated minors can advance
designate a representative payee.
SSA will collect the minimum information needed to help the agency contact the designated
individuals in the future. The beneficiary may waive, withdraw, select, update information, or
change the order of priority of the advance designee(s) at any time.
In addition, the law requires SSA to mail an annual notice to the beneficiaries with the name(s)
of any individual advance designated. The notice contains:
• Advance Designation of Representative Payee background information, and
• The list of the designee(s) submitted by the beneficiary.
This may result in approximately 59 million notices issued annually to beneficiaries.
This notice will be released through Customer Communications Management (CCM).

We are submitting this revised notice clearance package for the non-sensitive minor changes we
made to the existing notice. OCOMM suggested adding mySSA to enable eligible individuals to
provide advance designation or make changes on their own through their personal mySSA
account to lessen the customer service workload in the Field Office and the Teleservice Center.
These minor modifications do not involve any changes to policy.

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Section 2
ADVANCE DESIGNATION
OF REPRESENTATIVE PAYEE ANNUAL NOTICE

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Page 1 of 2

SOCIAL SECURITY
123 MAIN STREET
CITY ST 99999

Social Security Administration
Advance Designation of Representative Payee
September XX, 2020
BNC: XXXXXXXX

JANE DOE
10230 RICHARDSON DRIVE
ORLANDO FL 22222
SNO Options (generated if the individual has a SNO option)
SNO002
SNO004
We are writing to you because you provided us with your Advance Designation of
Representative Payee. This letter is an annual reminder of your designation.
Advance Designation
If you become unable to manage or direct the management of your benefits, we will select a
representative payee to receive and manage your benefits for you. Advance designation lets you
provide names of people who could serve as your representative payee. If the time comes that
you need someone to manage your benefits, we may select one of your advance designees as
your representative payee. We will consider your advance designees in your order of priority
with certain exceptions. To be appointed representative payee, an individual must be able and
willing to serve, and must meet our selection requirements.
Your Advance Designation Information
Below is a list of the designees you provided, in your order of priority, to serve as your
representative payee. Please take some time to review the information for accuracy:
Order of Priority
1
2
3

Name of Designee
John Doe
Joe Doe
Joe Public

Telephone Number
xxx-xxx-xxxx
xxx-xxx-xxxx
xxx-xxx-xxxx

Relationship
Spouse
Son
Friend

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Page 2 of 2
You can go online to your personal my Social Security account at www.ssa.gov/myaccount or
contact us to make the following changes to your designees:
• add or remove a designee,
• update a designee’s information,
• change the order of priority, or
• withdraw your advance designation of representative payee.
Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit https://oig.ssa.gov or call the Inspector
General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).
If You Have Questions (REFC07)
REF002 (foreign)
REF003 (domestic)
REF008 (no FO generated by zip)
Social Security Administration

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Section 3
ADVANCE DESIGNATION OF REPRESENTATIVE
PAYEE ANNUAL NOTICE

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Page 1 of 2

SOCIAL SECURITY
*F1 FO Address

Social Security Administration
Advance Designation of Representative Payee
*F2 Date
*F3 BNC#

*F4 BENEFICIARY NAME
*F5 Beneficiary Address
SNO Options (generated if the individual has a SNO option)
SNO002
SNO004
We are writing to you because you provided us with your Advance Designation of
Representative Payee. This letter is an annual reminder of your designation.
Advance Designation
If you become unable to manage or direct the management of your benefits, we will select a
representative payee to receive and manage your benefits for you. Advance designation lets you
provide names of people who could serve as your representative payee. If the time comes that
you need someone to manage your benefits, we may select one of your advance designees as
your representative payee. We will consider your advance designees in your order of priority
with certain exceptions. To be appointed representative payee, an individual must be able and
willing to serve, and meet our selection requirements.
Your Advance Designation Information
Below is a list of the designees you provided, in your order of priority, to serve as your
representative payee. Please take some time to review the information for accuracy:
Order of Priority
1
2
3

Name of Designee
*F6-001 Name of
Designee
*F6-002 Name of
Designee
*F6-003 Name of
Designee

Telephone Number
*F7-001 Designee
Phone Number
*F7-002 Designee
Phone Number
*F7-003 Designee
Phone Number

Relationship
*F8-001 Relationship
*F8-002 Relationship
*F8-003 Relationship

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Page 2 of 2
You can go online to your personal my Social Security account at www.ssa.gov/myaccount or
contact us to make the following changes to your designees:
• add or remove a designee,
• update a designee’s information,
• change the order of priority, or
• withdraw your advance designation of representative payee.

Suspect Social Security Fraud?
If you suspect Social Security fraud, please visit https://oig.ssa.gov or call the Inspector
General's Fraud Hotline at 1-800-269-0271 (TTY 1-866-501-2101).
If You Have Questions (REFC07)
REF002 (foreign)
REF003 (domestic)
REF008 (no FO generated by zip)
Social Security Administration

*F1 FO Address
*F2 Date
*F3 BNC#
*F4 BENEFICIARY NAME
*F5 Beneficiary Address
*F6: 001 Name of Designee/002 Name of Designee/003 Name of Designee
*F7: 001 Designee Phone Number/002 Designee Phone Number/003 Designee Phone Number
*F8: 001 Relationship/002 Relationship/003 Relationship

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
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 you provide to update and maintain your representative payee(s).
We may also share the information for the following purposes, called routine uses:
•

To third party contacts, where necessary, to establish or verify information provided
by representative payees or representative payee applicants; and

•

To contractors and other Federal Agencies, as necessary, for the purpose of assisting
us in the efficient administration of our programs. We will disclose information
under this routine use only in situations in which we may enter into a contractual or
similar agreement to obtain assistance in accomplishing an SSA function relating to
this system or records.

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(s)
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
October 31, 2019, at 84 FR 58422. Additional information, and a full listing of all 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
(OMB) control number. We estimate that it will take about 6 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.