RI 20-7 Representative Payee Application (2024; Mark-Up)

OMB Approval 3206-0140

United States
Office of Personnel Management
Retirement Services
P.O. Box 45
Boyers, PA 16017-0045

This form now starts with 2 pages of instructions.

Application for Selection as Representative Payee of an Annuitant
If an annuitant is unable to manage or direct the management of his/her payments made under the Civil Service Retirement
System (CSRS) or Federal Employees Retirement System (FERS), the Office of Personnel Management (OPM) requires that the
payments be made to a court appointed guardian/conservator, or to an OPM selected representative payee with the clear
understanding that the funds will be expended and conserved for the benefit of the annuitant. If the annuitant's full monthly
payment is not required to meet his/her current needs, the representative payee is required to conserve the unused amount for the
annuitant's future needs. The representative payee will be held accountable for the funds and will have to provide written reports,
as OPM requires, to show that the payments are being properly used for the annuitant. Further, representative payees are
obligated to notify OPM immediately when they are no longer acting on behalf of the annuitant, or of other changes in
circumstances that would impact their ability to carry out their duties. If an annuitant dies and is erroneously paid annuity after
death, the representative payee must promptly return the erroneous annuity paid. Such payments must be returned to the U.S.
Department of the Treasury. The representative payee will also be held liable for any misused funds. In addition to receiving
annuity payments, the representative payee is responsible for acting in the annuitant's best interest by authorizing the correct
Federal income tax withholding from the annuity using Internal Revenue Service (IRS) form W-4P, Withholding Certificate for
Pension or Annuity Payments. The representative payee can select the appropriate Federally sponsored health benefit coverage
when applicable.
Please read the following instructions carefully to avoid delay in processing your application.
Miscellaneous Instructions

An individual applying to be the representative payee must include unexpired photo identification (e.g., a driver's license,
passport, Federal ID, State ID, or U.S. Military ID) with the Application for Selection as Representative Payee of an Annuitant
(RI 20-7). This does not apply to an organization.
Only one person or organization may be selected as the approved representative payee on file. That party will be fiducially
responsible for submitting financial reports as requested by OPM.
OPM does not recognize a power of attorney (POA) or durable power of attorney (DPOA) for purposes of selecting a
representative payee. Accordingly, do not send the POA/DPOA document to OPM with the RI 20-7.
Court Appointed Guardian or Conservator

If there is a court appointed guardian or conservator, including the estate, property, or plenary, an individual or an organization
may apply to become the representative payee by completing the RI 20-7, and mailing it to OPM with an original or a certified
copy of the court order. If you do not have the type of court order described above, or if you have a temporary or emergency court
order with an expiration date of less than one year, we will need additional information as required in the OPM Selected
Representative Payee section below.
Note that the following types of court orders are not acceptable by OPM and will be returned to the applicant:

‣
‣

Photocopies that have not been certified
A guardianship/conservatorship of the person only

Previous editions are not usable

RI 20-7
Revised February 2024

OPM Selected Representative Payee

If a court appointed guardian or conservator, including the estate, property, or plenary, has not been ordered by the court, an
individual, or an organization may apply to be an OPM selected representative payee by completing the RI 20-7. If the annuitant
has not been found to be incompetent by the court, the following information is required to make a determination concerning the
annuitant's competency and ability to manage his/her benefits:
1) A statement from a physician or other licensed health practitioner who has been treating the individual. The individual, or
representative is responsible for any cost incurred in obtaining this documentation. The medical diagnosis, on his/her
letterhead, must address the alleged incompetency, including:

• A history of the specific medical condition(s) which caused the individual to be incompetent, including symptoms,
physical findings, results of laboratory studies, and response to therapy.

• The diagnosis should be in accordance with International Statistical Classification of Diseases and Related Health

Problems (ICD) terminology or, in the case of psychiatric disorders, with Diagnostic and Statistical Manual of Mental
Disorders (DSM) criteria.

• The duration of the medical condition(s), including the date the condition caused incompetency and the date, or expected
date, of full or partial recovery.

2) Affidavits from at least two people who know the facts of the individual's competency, preferably one from a member of the
individual's immediate family, and one from a non-family member. The affidavits must be sworn to, or affirmed before a
notary public, or other officer who is authorized by law to administer oaths. The affidavits should state:

• The relationship to and amount of contact with the individual during the relevant period.
• What actions or incidents were personally observed that would indicate that the individual's condition interfered with the
ability to handle his/her personal affairs and how often these incidents were observed.

• The reason why a fiduciary was not appointed by the court to handle the individual's finances.
• Who is currently administering the individual's finances.
Checklist

 Answer all questions on the RI 20-7. Use additional sheets of paper if necessary.
 An original signature is required. If signing on behalf of an organization, an authorized signatory must sign and write "for"
followed by the name of the organization after their signature.

 An individual applying to be the representative payee must include an unexpired photo ID, as previously explained.
 If applying as a court appointed guardian or conservator, be sure to include an original, or certified copy, of a guardianship or
conservatorship court order including the estate, property, or plenary as explained above.

 If applying as an OPM selected representative payee, be sure to include the medical documentation, and two affidavits, as
explained above.

 If direct deposit, a voided check is required. To prevent commingling of funds, only a spouse may have a joint bank account
with the annuitant. The annuitant's name is required on the account. Example: Fiduciary's Name for Annuitant's Name.

 Incomplete applications will be returned to the applicant. A faxed application is not acceptable. Mail the completed

application, with the court order or required medical documentation and affidavits, to: U.S. Office of Personnel
Management, Retirement Services, Attn: Rep Payee, PO Box 45, Boyers, PA 16017-0045.

For more information, you may call the Retirement Information Office at 1-888-767-6738, Monday through Friday (excluding
Federal holidays), between 7:40 a.m. and 5:00 p.m. Eastern time, or write to us at the address shown above. Hearing impaired
users should utilize the Federal Relay Service by dialing 711, or their local communications provider, to reach a Communications
Assistant.

Application For Selection As Representative Payee of an Annuitant

OPM places a significant amount of responsibility on the representative payee. Consequently, OPM is interested in selecting the
most suitable person to be the annuitant's fiduciary. Therefore, it is necessary to determine your relationship to the annuitant and
the extent of your ability to direct the management of benefits under CSRS or FERS in the best interests of the annuitant. If you
have any questions regarding this form, you may contact OPM at 1-888-767-6738. Hearing impaired users should utilize the
Federal Relay Service by dialing 711, or their local communications provider, to reach a Communications Assistant.
Answer completely. Give explanations where required. Attach additional sheets if necessary.
Part A - Information About the Annuitant
1. Annuitant's claim number (CSA/CSF) 2. Annuitant's full SSN

3. Annuitant's name

4. Annuitant's complete physical address (This is not necessarily the same as the mailing address.)
5. Does the annuitant live (check one):

Alone

In a facility

In a private residence*

*If living in a private residence, please provide the information below for all other individuals living in the residence.
Name

Relationship

Name

Relationship

6. Why is the annuitant unable to manage or direct the management of his/her annuity?
7. If the annuitant is not a minor, has the annuitant been found incompetent by a State court?
Yes (Enclose an original or certified copy of the court order as described in the instructions. A photocopy that has not been certified is not
acceptable. OPM does not recognize a power of attorney (POA) or durable POA (DPOA). Do not submit this type of document with this
application.)
No (Enclose the medical documentation showing incompetence and two affidavits as described in the instructions.)
8. To your knowledge, has any individual or organization, other than yourself, been appointed or applied for appointment by a State court as a guardian or
conservator charged with fiduciary responsibility of the annuitant's estate?
Yes (Provide that person's name and address below and explain why you think it would be in the annuitant's best interest that payment be made
to you.)
No
9. If the annuitant is a minor, and the applicant is not the parent, does the child have a living natural/adoptive parent?
Yes (Provide the name, address, and telephone number of the parent.)

No

N/A

Does the parent show interest in the child?
Yes
No (Explain below.)

Part B - Information About the Applicant
1. Applicant's name

2. If an Individual, enter applicant's
SSN. If an Organization, enter
applicant's EIN

3. If an Individual, enter applicant's
date of birth (mm/dd/yyyy)

4. If an Individual, list other names used by applicant (Marital, maiden, etc.,
if applicable.)
5. Applicant's address

6. Applicant's relationship to annuitant

Continue Part B on the other side of this page.

RI 20-7
Revised February 2024

7. Do you live within commuting distance of the annuitant?
Yes

8. Have you assumed the responsibility for the annuitant's routine expenses?
Yes

No (Explain how you will manage the annuitant's affairs.)

No (Provide the name and address of the person who assumed these
responsibilities.)

9. Do you have any prior experience as a representative payee?
Yes (Explain below.)

No

10. Have you ever been dismissed as a representative payee?
Yes (Explain below.)

No

11. Have you assumed the responsibility for providing care for the annuitant?
Yes (If the annuitant lives with you, who takes care of the
annuitant when work or another activity takes you away
from home?)

No (Provide the name and address of the person who assumed
these responsibilities.)

12. Explain below how you will use the annuity payments to benefit the annuitant.

13. Explain below how you will conserve the annuitant's payments if they are not required to meet the annuitant's current needs.

Part C - Additional Information About an Individual Applicant (Organizations May Skip this Section)
1. Are you currently employed?
Yes (List your employer's name and address.)

No (What is your main source of income?)

2. Have you ever been convicted of a felony? (Including, but not limited to, violations of 5 U.S.C. 8345a or 8466a; section 208 or 1632 of the Social Security
Act (42 U.S.C. 408 or 1383a); 38 U.S.C. 6101 or any offense resulting in imprisonment for more than one year.)
Yes (Answer a-e below.)
a. On what date (mm/dd/yyyy) were you convicted?

d. If in prison, when (mm/dd/yyyy) were you released?

b. What was the crime?

e. If probation was ordered, when (mm/dd/yyyy) did/will your
probation end?

c. What was your sentence?

No (Skip to #3.)
3. Do you have any unsatisfied felony warrants for your arrest?
Yes (Provide the date [mm/dd/yyyy] of the warrant below.)

No

_____________________________________________________

Continue Part D on the next page.

Part D - Direct Deposit
With the exception of spouses with a joint account, a separate account is required to administer the annuitant's funds. The annuitant's name is required on
the account.
No change to the current direct deposit account.
The permanent payment address is outside the United States in a country not accessible via direct deposit.
Change the deposit account:
(A voided check is required.)

Type of account:

Checking

Savings

Account number: ___________________________________
Bank routing number: _______________________________

Part E - Certification
I certify that the above information is correct. I hereby affirm that I will comply with the following requirements if I am selected as the
representative payee for the annuitant.
(1) I agree to promptly notify OPM in writing when I can no longer act in the best interest of the annuitant.
(2) I agree to promptly submit such written accountability reports as OPM may require.
(3) I agree to promptly notify OPM if the annuitant or I move from the address I furnished in Part A and Part B.
(4) I agree to promptly notify OPM if the annuitant recovers the capacity to manage their own business affairs.
(5) I agree to promptly notify OPM if the annuitant dies.
(6) I agree to promptly notify OPM if the disabled child dependent marries or becomes self supporting.
(7) I understand that I am subject to a background check based on the terms of the Representative Payee Fraud Prevention Act of 2019.
(8) I agree that I will return any payments which I receive after the annuitant's death . I understand that all such payments will be considered
debt to the U.S. Government and are to be immediately returned to the U.S. Department of the Treasury. I further understand that if I
misuse payments that are erroneously paid to an annuitant after death, I will be responsible for repayment of the benefits erroneously
paid and OPM will seek restitution from me for those misused funds.
(9) I acknowledge that the Representative Payee Fraud Prevention Act of 2019 grants OPM the authority to revoke certification as a
representative payee (including an organization), if they determine that a representative payee has embezzled, or converted the
annuity payments, and to certify payments to another representative payee, or directly to the annuitant (5 C.F.R. 849.501[a]).
Congress set forth the penalty for misuse of benefits by a representative payee, under title 18 U.S.C., as a fine, imprisonment for
not more than 5 years, or both (5 C.F.R. 849.501[b]).
Warning: Any intentionally false statement, willful concealment of a material fact, or use of a document knowing the same to contain false,
fictitious, or fraudulent statements or entry is a violation of the law punishable by a fine of not more than $10,000 or imprisonment
of not more than 5 years or both (18 U.S.C. 1001).
Applicant's signature (Original signature required. If signing on behalf of an
organization, an authorized signatory must sign and write "for" followed by the
name of the organization after your signature.)

Telephone number (including area code)

Date (mm/dd/yyyy)

E-mail address
Privacy Act Statement

Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why OPM is requesting the information on this form.
Authority: OPM is authorized to collect the information requested on this form by 5 U.S.C. § 8345 and 8466 which provides that payment
due to a minor, or an individual mentally incompetent or under legal disability, may be made to the person who is constituted guardian or
other fiduciary by the law of the State of residence of the claimant or is otherwise vested with the care of the claimant or his estate. OPM is
authorized to collect your Social Security number by Executive Order 9397 (November 22, 1943), as amended by Executive Order 13478
(November 18, 2008). Purpose: OPM is requesting this information in order to determine if you will be selected as payee for the annuitant.
Routine Uses: The information requested on this form may be shared externally as a "routine use" to other Federal agencies and third-parties
when it is necessary to process your request. For example, OPM may share your information with other Federal, state, or local agencies and
organizations in order to determine benefits under their programs, to obtain information necessary for a determination of your suitability,
or to report income for tax purposes. OPM may also share your information with law enforcement agencies if it becomes aware of a violation
or potential violation of civil or criminal law. A complete list of the routine uses can be found in the OPM/CENTRAL 1 Civil Service
Retirement and Insurance Records systems of records notice, available at www.opm.gov/privacy. Consequences of Failure to Provide
Information: Providing this information is voluntary. However, failure to provide this information may delay or prevent OPM from being
able to select you as payee for the annuitant.
Public Burden Statement

The public reporting burden to complete this information collection is estimated at 30 minutes per response, including time for reviewing the
collected instructions, searching data sources, gathering and maintaining the data needed, and completing and reviewing of the collected
information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays
a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden to the Office of Personnel Management, Retirement Services Publications Team at
[email protected]. Current information regarding this collection of information -- including all background materials -- can be
found at https:/www.reginfo.gov/public/do/PRAMain by using the search function to enter either the title of the collection or 3206-0140.
Reverse of RI 20-7
Revised February 2024