Form SSA-322 Beneficiary Interview and Auditor's Observations

FORM APPROVED
OMB NO. 0960-0630

BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS
Privacy Act and Paperwork Reduction Act Statements
See Revise Privacy Act Statement
The Privacy Act requires us to notify you that we are authorized to collect this
information by sections 205 and 1631 of the Social Security Act. You do not
have to provide the information requested. However, the information you
provide will allow the Social Security Administration (SSA) to insure the integrity
of the representative payee program and supplement other data needed to
determine whether representative payees are complying with their duties. The
person(s) completing the form will remain anonymous.
This information collection meets the clearance requirements of 44 U.S.C. §
3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You
are not required to answer these questions unless we display a valid Office of
Management and Budget control number. We estimate that it will take you
about 15 minutes to read the instructions, gather the necessary facts, and
answer the questions. See Revised PRA Statement

SSA FORM - 322

1

FORM APPROVED
OMB NO. 0960-0630

BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS
Beneficiary Information
Name: ___________________

SSN: _________________

Age: _______

Beneficiary Interview (ask the beneficiary and/or caregiver the following questions)
1. Are you satisfied with the living arrangements provided by the rep payee?




Yes
No

If no, obtain the beneficiary’s explanation

SSA FORM - 322

2

FORM APPROVED
OMB NO. 0960-0630

BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS
2. Are you satisfied with the clothing and personal items provided by the rep payee?




Yes
No

If no, obtain the beneficiary’s explanation

SSA FORM - 322

3

FORM APPROVED
OMB NO. 0960-0630

BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS
3. Are you satisfied with the food provided by the rep payee?




Yes
No

If no, obtain the beneficiary’s explanation.

SSA FORM - 322

4

FORM APPROVED
OMB NO. 0960-0630

BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS
4. Does the rep payee pay your bills in a timely manner?




Yes
No

If no, obtain the beneficiary’s explanation

SSA FORM - 322

5

FORM APPROVED
OMB NO. 0960-0630

BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS
5. Does the rep payee let you know how much money he/she has saved for you?




Yes
No

If no, obtain the beneficiary’s explanation

SSA FORM - 322

6

FORM APPROVED
OMB NO. 0960-0630

BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS
6. Other comments or observations of the beneficiary

SSA FORM - 322

7

FORM APPROVED
OMB NO. 0960-0630

BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS
Auditor’s Observations
1. Does the living quarters and housing appear to be adequate?




Yes
No

If no, explain

SSA FORM - 322

8

FORM APPROVED
OMB NO. 0960-0630

BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS
2. Does the beneficiary’s wardrobe and clothes appear to be adequate?




Yes
No

If no, explain

SSA FORM - 322

9

FORM APPROVED
OMB NO. 0960-0630

BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS
3. Does it appear that the beneficiary is provided adequate food and medicine (if
applicable)?




Yes
No

If no, explain

SSA FORM - 322

10

SSA will insert the following revised Privacy Act Statement into the form
at its next scheduled reprinting:
Privacy Act Statement
Beneficiary Interview and Auditor’s Observations
Sections 107, 205, and 1631 of the Social Security Act, as amended, authorize us to
collect this information. The information you provide will allow the Social Security
Administration (SSA) to insure the integrity of the representative payee program and
supplement other data needed to determine whether representative payees are complying
with their duties.
The person(s) completing the form will remain anonymous. Your response is voluntary.
However, failure to provide this requested information may prevent an accurate and
timely decision on any claim filed, or could result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for the
reasons stated above. 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 the following:
1) To enable a third party or an agency to assist Social Security in establishing
rights to Medicare benefits 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’s Affairs);
3) To make determination 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 Medicare programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our 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 or administered benefit programs and for
repayment of payments or delinquent debts under these programs.
Explanations about these and other reasons why information you provide us may be used
or given out are available in Systems of Record Notice 60-0370 (Representative Payee
and Beneficiary Survey Data System, SSA/Office of Income Security Programs. The
Notice information about this form, and any other information regarding our systems and

programs, are available on-line at www.socialsecurty.gov or at your local Social Security
office.

SSA will insert the following revised Privacy Act Statement into the form
at its next scheduled reprinting:
Privacy Act Statement
Beneficiary Interview and Auditor’s Observations
Sections 107, 205, and 1631 of the Social Security Act, as amended, authorize us to
collect this information. The information you provide will allow the Social Security
Administration (SSA) to insure the integrity of the representative payee program and
supplement other data needed to determine whether representative payees are complying
with their duties.
The person(s) completing the form will remain anonymous. Your response is voluntary.
However, failure to provide this requested information may prevent an accurate and
timely decision on any claim filed, or could result in the loss of benefits.
We rarely use the information provided on this form for any purpose other than for the
reasons stated above. 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 the following:
1) To enable a third party or an agency to assist Social Security in establishing
rights to Medicare benefits 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’s Affairs);
3) To make determination 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 Medicare programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our 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 or administered benefit programs and for
repayment of payments or delinquent debts under these programs.
Explanations about these and other reasons why information you provide us may be used
or given out are available in Systems of Record Notice 60-0370 (Representative Payee
and Beneficiary Survey Data System, SSA/Office of Income Security Programs. The
Notice information about this form, and any other information regarding our systems and

programs, are available on-line at www.socialsecurty.gov or at your local Social Security
office.

SSA will insert the following revised PRA Statement 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 15
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.