Application For Individuals Not Currently Working with a Payee

If you are not currently working with a payee, and you have not been informed by Social Security that you need a payee:

    1. you must have a medical treatment provider sign and complete Form 787.
      (This form can be completed by your treating physician, nurse practioner, or Mental health doctor.

    2. Review and sign the intake referral form.

    3. If the client is willing to sign, Please have the sign and complete SSA Form 4164 Advance Notification of Representative payment. It is not required but will make the appointment process go much faster.

    4. Return both of these forms to our office via mail fax or email.

What happens from here?

After all needed information is provided, SSSA will submit Form SSA11: Request to be selected as Payee to the Social Security Administration. After the Social Security administration has appointed us as your payee you will be notified by mail that SSSA has requested to become your new payee. You will be given 15 days to contest the application. If you do not respond, in person, by that time, the application will be processed, and SSSA will become your new representative payee.

Once we have been appointed as your payee we ask that you

  • Provide us with information regarding your monthly expenses and a copy of your rental lease if applicable.

  • Provide us with a current mailinsg address where you can receive checks and correspondence (we do require that all of our clients have a mailing address)

  • Contact your utility companies (water, gas, electric, telephone, cell phone, TV, medical bills) that may issue you a monthly billing statement and change the billing address to come directly to our offices.

      Your name
      PO Box 1466
      Glendale, AZ 85301

By doing the above we can schedule timely payments beginning the first month that we receive your benefits.

If you have any questions about any section of the application process, please feel free to contact us. This can be done through email at info@reppayee.org, or by telephone at 623.414.4425, Monday through Friday between the hours of 8:00 a.m. to 5:00 p.m.

Please Note:

It can often take one month or more for the Social Security Administration to complete the process of appointing us as your payee. We ask for your patience during this period. Until we are appointed, due to privacy laws we will be unable to obtain any information from the Social Security Administration regarding your benefit. Our staff will do our best to advocate on your behalf.