1. Signature of Witness Address Number of Street City State and ZIP Code Form SSA-4164 5/91 Destroy Prior Editions. Advance Notification of Representative Payment Name of Wage Earner Self-Employed Person or SSI Claimant Social Security Number Name of beneficiary if other than above Relationship to Wage Earner Self Employed Person or SSI Claimant I understand and agree with the following Need for Representative...
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SSA 4164, Representative Payee Form.
This form is used when requesting that a representative payee such as Resource Oversight & Guidance Services take over management of Social Security or SSI payments.
Form SSA-787, Capability of Benefit Management Statement.