I4547 (internet version)

REVISED - ADVANCE DESIGNATION OF REPRESENTATIVE
PAYEE BENEFICIARIES AND APPLICANTS RECEIPTS
SOCIAL SECURITY ADMINISTRATION
NOTICE CLEARANCE PACKAGE

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Table of Contents
Contents
Section 1 ....................................................................................................................................................... 3
REVISED - BACKGROUND ................................................................................................................ 3
Section 2 ....................................................................................................................................................... 5
REVISED - ADVANCE DESIGNATION OF REPRESENTATIVE PAYEE RECEIPTS FOR
INITIAL SUBMISSION AND UPDATES ........................................................................................... 5
Section 3 ....................................................................................................................................................... 9
REVISED WITH FILL-INS - ADVANCE DESIGNATION OF REPRESENTATIVE PAYEE
RECEIPTS FOR INITIAL SUBMISSION AND UPDATES ........................................................... 11
*F1 FO Address ................................................................................................................................. 11
*F2 Date ............................................................................................................................................. 11
*F3 BNC# .......................................................................................................................................... 11
*F4 BENEFICIARY/APPLICANT NAME ...................................................................................... 11
*F5 Beneficiary/Applicant Address ................................................................................................... 11
*F6 Date of Designation/updated ....................................................................................................... 11
*F7 gave us/updated ........................................................................................................................... 11
*F8: 001 Name of Designee/002 Name of Designee/003 Name of Designee ................................... 11
*F9: 001 Designee Phone Number/002 Designee Phone Number/003 Designee Phone Number ..... 11
*F10: 001 Relationship/002 Relationship/003 Relationship .............................................................. 11
Section 4 ..................................................................................................................................................... 13
REVISED - ADVANCE DESIGNATION OF REPRESENTATIVE PAYEE RECEIPTS FOR
WAIVER OR WITHDRAWAL .......................................................................................................... 13
Section 5 ..................................................................................................................................................... 16
REVISED WITH FILL-INS - ADVANCE DESIGNATION OF REPRESENTATIVE PAYEE
RECEIPTS FOR WAIVER OR WITHDRAWAL ............................................................................ 16
*F1 FO Address ................................................................................................................................. 17
*F2 Date ............................................................................................................................................. 17
*F3 BNC# .......................................................................................................................................... 17
*F4 BENEFICIARY/APPLICANT NAME ...................................................................................... 17
*F5 Beneficiary/Applicant Address ................................................................................................... 18
*F6 WITHDRAWAL/WAIVER........................................................................................................ 18
*F7 Date of Submission ..................................................................................................................... 18
*F8 withdrew your/waived................................................................................................................. 18

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Section 1
REVISED - 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. Section 201 of the law allows claimants and
beneficiaries to designate one or more individuals to serve as a representative payee should they
need one in the future and requires the Social Security Administration (SSA) to select the
designated individual (with certain exceptions). SSA will provide this option to beneficiaries
receiving Title 2, Title 8, and Title 16 benefits and applicants during an initial claim for these
programs. Only adults age 18 and over and emancipated minors can advance designate as long as
they do not have a representative payee or have a pending representative payee application in
process.
SSA will collect the minimum information needed to help the agency contact the designated
individuals in the future. The beneficiary may waive, withdraw, update information, or change
the order of priority of the advance designee(s) at any time.
As part of the business process, SSA will provide the applicants and beneficiaries with a receipt
for each transaction. This may result in approximately 59 million receipts issued annually to
applicants and beneficiaries.
We are submitting this revised notice clearance package for ADRP receipts to request approval
for non-sensitive minor changes to the existing receipts. 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. We also included a formatting change to move the field office address
from top right side to the left side of the receipts, and changed the date criteria to calculate using
normal date rules instead of current date because the receipts will be centrally printed. The
updates do not involve any changes to policy.

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Section 2
REVISED - ADVANCE DESIGNATION OF REPRESENTATIVE
PAYEE RECEIPTS FOR INITIAL SUBMISSION AND UPDATES

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SOCIAL SECURITY
123 MAIN STREET
CITY ST 99999

Social Security Administration
Receipt for Advance Designation of
Representative Payee
Date: (Use normal date rules)
BNC#:XXAXXXXAXXXX

JOHN DOE
10230 RICHARDSON DRIVE
ORLANDO FL, 22222
SNO Options (generated if the individual has a SNO option)
SNO015
SNO016
ADVANCE DESIGNATION OF REPRESENTATIVE PAYEE FOR JOHN DOE.
On March 25, 2019, you gave us your advance designation of representative payee information.
This letter gives you more information about your 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.
Below is a list of the one or more 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
Jane Doe
Joe Public

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

Relationship
Son
Spouse
Friend

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 the designee’s information,
• Change the order of priority, or
• Withdraw your advance designation of representative payee.

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If You Have Questions (REFC07)
REF002 (foreign)
REF003 (domestic)
REF008 (no FO generated by zip)

Social Security Administration

8
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 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
(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 relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

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Section 3
REVISED WITH FILL-INS - ADVANCE DESIGNATION
OF REPRESENTATIVE PAYEE RECEIPTS
FOR INITIAL SUBMISSION AND UPDATES

10
SOCIAL SECURITY
*F1 FO Address

Social Security Administration
Receipt for Advance Designation of
Representative Payee
*F2 Date (Use normal date rules)
*F3 BNC#

*F4 BENEFICIARY/APPLICANT NAME
*F5 Beneficiary/Applicant Address
SNO Options (generated if the individual has a SNO option)
SNO015
SNO016
ADVANCE DESIGNATION OF REPRESENTATIVE PAYEE FOR *F4
BENEFICIARY/APPLICANT NAME
On *F6 Date of Designation, you *F7 gave us/updated your advance designation of
representative payee information. This letter gives you more information about your
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.
Below is a list of the one or more 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
*F8-001 Name of
Designee
*F8-002 Name of
Designee
*F8-003 Name of
Designee

Telephone Number
*F9-001 Designee
Phone Number
*F9-002 Designee
Phone Number
*F9-003 Designee
Phone Number

Relationship
*F10-001
Relationship
*F10-002
Relationship
*F10-003
Relationship

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,
• Updated the designee’s information,

11
•
•

Change the order of priority, or
Withdraw your advance designation of representative payee.

If You Have Questions (REFC07)
REF002 (foreign)
REF003 (domestic)
REF008 (no FO generated by zip)

Social Security Administration

*F1 FO Address
*F2 Date (Calculate using normal date rules instead of current date.)
*F3 BNC#
*F4 BENEFICIARY/APPLICANT NAME
*F5 Beneficiary/Applicant Address
*F6 Date of Designation/updated
*F7 gave us/updated
*F8: 001 Name of Designee/002 Name of Designee/003 Name of Designee
*F9: 001 Designee Phone Number/002 Designee Phone Number/003 Designee Phone Number
*F10: 001 Relationship/002 Relationship/003 Relationship

12

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 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
(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 relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

13

Section 4
REVISED - ADVANCE DESIGNATION OF REPRESENTATIVE
PAYEE RECEIPTS FOR WAIVER OR WITHDRAWAL

14
SOCIAL SECURITY
123 MAIN STREET
CITY ST 99999

Social Security Administration
Important Information
Date: (Use normal date rules)
BNC#: XXAXXXXAXXXX

JOHN DOE
10230 RICHARDSON DRIVE
ORLANDO FL, 22222
SNO Options (generated if the individual has a SNO option)
SNO015
SNO016
WITHDRAWAL OF ADVANCE DESIGNATION OF REPRESENTATIVE PAYEE FOR
JOHN DOE
On March 25, 2019, you withdrew your advance designation of representative payee.
Advance designation of a representative payee allows you to provide us with the name of one or
more people, in your order of priority, to serve as your representative payee. If you are unable
to manage or direct the management of your benefits, we will select a representative payee to
receive and manage your benefits for you.
Please log in to your personal my Social Security account at www.ssa.gov/myaccount or contact
us if you decide to participate in advance designation of representative payee in the future.
If You Have Questions (REFC07)
REF002 (foreign)
REF003 (domestic)
REF008 (no FO generated by zip)

Social Security Administration

15
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 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.

16

Section 5
REVISED WITH FILL-INS - ADVANCE DESIGNATION OF
REPRESENTATIVE PAYEE RECEIPTS FOR
WAIVER OR WITHDRAWAL

17
SOCIAL SECURITY
*F1 FO Address

Social Security Administration
Important Information
*F2 Date (Use normal date rules)
*F3 BNC#

*F4 BENEFICIARY/APPLICANT NAME
*F5 Beneficiary/Applicant Address
SNO Options (generated if the individual has a SNO option)
SNO015
SNO016
*F6 WITHDRAWAL/WAIVER OF ADVANCE DESIGNATION OF REPRESENTATIVE
PAYEE FOR *F4 BENEFICIARY/APPLICANT NAME.
On *F7 Date of Submission, you *F8 withdrew your/waived advance designation of
representative payee.
Advance designation of a representative payee allows you to provide us with the name of one or
more people, in your order of priority, to serve as your representative payee. If you are unable to
manage or direct the management of your benefits, we will select a representative payee to
receive and manage your benefits for you.
Please log in to your personal my Social Security account at www.ssa.gov/myaccount or contact
us if you decide to participate in advance designation of representative payee in the future.
If You Have Questions (REFC07)
REF002 (foreign)
REF003 (domestic)
REF008 (no FO generated by zip)
Social Security Administration
*F1 FO Address
*F2 Date (Calculate using normal date rules instead of current date.)
*F3 BNC#
*F4 BENEFICIARY/APPLICANT NAME

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*F5 Beneficiary/Applicant Address
*F6 WITHDRAWAL/WAIVER
*F7 Date of Submission
*F8 withdrew your/waived

19

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 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
(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 relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.