Form SSA-445 Application to Collect a Fee for Payee Services (State/l

See below for revised Privacy Act Statement.

See below for revised Paperwork
Reduction Act Statement.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 10
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.

Privacy Act Statement
Sections 205(j)(4) and 1631(a)(2), of the Social Security Act, as amended, authorize us to
collect this information. The information is needed to permit consideration as to your
eligibility to serve as a Fee for Service Representative Payee. The information you
furnish on this form is voluntary. However, failure to provide all or part of the
information may result in nonpayment for your services.
We rarely use the information you supply for any purpose other than for making a
determination regarding your eligibility to serve as a Fee for Service Representative
Payee. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to: (1) to
enable a third party or an agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage; (2) to comply with Federal laws requiring the release
of information from Social Security records (e.g., to the Government Accountability
Office and Department of Veteran Affairs); (3) to make determinations for eligibility in
similar health and income maintenance programs at the Federal, State, and local level;
and (4) to facilitate statistical research, audit, or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local
government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally-funded and administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Record
Notice 60-0222. This notice, additional information regarding this form, and information
regarding our programs and systems, are available on-line at www.socialsecurity.gov or
at your local Social Security office.