Effective Dates: 01/08/2004 - Present Previous | Next

TN 15 (01-04)

RS 02801.500 SSA-795, Statement of Claimant or Other Person – For Immediate Payment Cases – Required Language

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.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0302801500
RS 02801.500 - SSA-795, Statement of Claimant or Other Person – For Immediate Payment Cases – Required Language - 01/08/2004
Batch run: 09/06/2019
Rev:01/08/2004