Application to Act as Representative Payee

ICR 202303-3220-001

OMB: 3220-0052

Federal Form Document

Forms and Documents

Document Name	Status
Form AA-5 Application for Substitution of Payee and Duties As Representative Payee (Individuals) Form	Modified
Form G-478 Statement Regarding Patient's Capability to Manage Payments Form and Instruction	Modified
Form AA-5 Application for Substitution of Payee and Duties as Representative Payee (Institutions) Form and Instruction	Modified
3220-0052.docx Supporting Statement A	2023-03-28

IC Document Collections

IC ID	Document Title	Status
33865	Application for Substitution of Payee and Duties As Representative Payee (Individuals) Form	Modified
179885	Statement Regarding Patient's Capability to Manage Payments Form and Instruction	Modified
179617	Application for Substitution of Payee and Duties as Representative Payee (Institutions) Form and Instruction	Modified