SSA-4547 - Current

Form SSA-4547 (08-2023)
Discontinue Prior Editions
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 or to make necessary changes.
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

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

Order of Priority

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.
SIGNATURE (Write in ink)

Date (Month, Day, Year)

Telephone (Area Code/Country Code and Number)

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

City

State/Country

ZIP Code

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 (08-2023)

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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 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 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 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. Send only comments relating to our time
estimate or other aspects of this collection to this address, not the completed form.