TN 15 (01-04)

Use the latest version of the SSA-795, Statement of Claimant or Other Person, available on the SSA e-forms with the following language.

“I (print full name of individual or representative payee) Claim

Number ________________ acknowledge receipt of a Title II

Immediate Payment in the amount of $_______. I understand that I may receive duplicate payments based on this current request for payment. I agree to repay any overpayment that may result from receiving duplicate payments.

Have the individual or representative payee sign the Form SSA-795 and give a copy to the individual or representative payee as a receipt and notice.