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ADOBE ACROBAT 

DF AS FORM 9415, JUNE 2022

REPRESENTATIVE PAYEE - CERTIFICATION

PRIVACY ACT STATEMENT

Authority: P. L. 102-190, Sec. 654 

Principal Purpose: To establish a representative payee to receive survivor annuity payments on behalf of a minor, mentally incompetent, or otherwise legally 

disabled person for whom a guardian or other fiduciary has not been appointed. 

Routine Use(s): Information may be released to the Internal Revenue Service for tax administration; General Accounting Office for auditing; Dept. of Veterans 

Affairs for pay entitlements; Social Security Administration for pay entitlements; American Red Cross for locator service; Air Force Aid Society 

for family assistance; and Office of Personnel Management for pay entitlements. 

Disclosure: Voluntary; however, failure to furnish requested information may result in non-appointment as a representative payee. 

REPRESENTATIVE PAYEE CERTIFICATION 

1. As representative payee I certify by my signature on this form that I will spend or invest the annuity paid to me on behalf of the annuitant solely for the benefit 

of the annuitant. 

2. As representative payee I agree to maintain and, upon request, provide a periodic accounting of expenditures and investments of amounts paid to me on 

behalf of the annuitant. I understand that in situations where a periodic accounting is required, it will ordinarily be submitted annually unless I am asked to submit 

a financial accounting more frequently. Final financial accounting will be required upon loss of beneficiary's eligibility, a change in representative payee, or a later 

determination of competency of the annuitant. 

3. As representative payee, I understand that I may be asked to provide a surety bond in an amount sufficient to protect the interests of the annuitant. I 

understand that I may pay for such bond(s) out of the survivor annuity. 

4. As a representative payee, I will request prior written approval through the appropriate DFAS Center for major expenditures from the bank account I maintain 

on behalf of the annuitant. Major expenditures are those in excess of $1,000 or one year's survivor annuity, whichever is less.

5. I understand that if the appropriate DFAS Center receives evidence that suggest the annuity funds have been or are being misused, the annuity may be 

suspended. If annuity payments are suspended, an investigation will be conducted to determine if a new representative payee should be appointed or if 

payments may be resumed.

6. I understand that if the appropriate DFAS Center receives more than one application for representative payee, the Secretary concerned shall make the 

determination as to which applicant is the more appropriate payee. 

7. As representative payee, I agree to submit reports of existence and certificates of continued eligibility as requested by the DFAS Center. 

8. An annuity paid to a person on behalf of an annuitant to a representative payee discharges the obligation of the United States for payment to the annuitant of 

the amount of the annuity paid. 

REPRESENTATIVE PAYEE - APPLICATION

PART I -REPRESENTATIVE PAYEE APPLICANT/ANNUITANT INFORMATION 

Annuitant's Name (Last, First, Middle Initial) SSN

Name of Representative Payee Applicant

Relationship to Annuitant Correspondence Address Email Address Telephone Number 

Check Mailing Address: SEE ATTACHED DIRECT DEPOSIT FORM

Comments

PART II - INCOMPETENCY DOCUMENTATION 

If the annuitant has been determined to be incompetent to manage financial affairs, please attach the determination of incompetency from a state court, physician or 

psychologist. Please note that once a person has been declared to be incapable of handling their affairs a Power of Attorney of any type is no longer acceptable.

 PART III - TRUSTEESHIP 

If representative payee applicant is the trustee of a trust for benefit of the annuitant, please provide a copy of the trust agreement designating the representative 

payee as the individual who is to receive payments on behalf of the annuitant. 

PART IV - CERTIFICATION 

I certify that I have read the conditions on this application and as evidenced by my signature below hereby agree to the conditions set forth. 

SIGNATURE OF REPRESENTATIVE PAYEE APPLICANT DATE

SIGNATURE OF WITNESS DATE

SIGNATURE OF WITNESS DATE