TN 15 (01-04)
RS 02801.500 SSA-795, Statement of Claimant or Other Person – For Immediate Payment Cases – Required
Use the latest version of the SSA-795, Statement of Claimant or Other Person, available on the SSA e-forms with the following
“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.