Form SSA-322 Beneficiary Interview and Auditor's Observations

FORM APPROVED
OMB NO. 0960-0630

BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS

Privacy Act Statement
The Inspector General Act of 1978, as amended (5 U.S.C. App. 3), and Sections 205 and
1631 of the Social Security Act, as amended (42 U.S.C. §§ 405 and 1383), authorizes the
collection of this information. The information you provide will allow the Office of Inspector
General (OIG) and 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 and responsibilities.
Your response is voluntary and you will remain anonymous in any publicly issued OIG Audit
Reports. However, failure to provide this requested information could ultimately prevent SSA
from making an accurate and timely decision on any claim filed, or could result in the loss of
benefits.
The primary purpose of the information that you submit is for use by the OIG as part of its
review of SSA’s representative payee program. However, the information may also be used
by SSA for the administration and integrity of its Social Security programs. The information
that you provide may also be disclosed by either the OIG and/or SSA to another person
and/or to another agency/entity in accordance with approved routine uses pertaining to the
relevant Systems of Records to which any information that you provide is incorporated. The
relevant OIG Systems of Records are the Criminal Investigative Files of the Inspector
General, SSA/OIG (system number OIG-001) and the Civil and Administrative Investigative
Files of the Inspector General, SSA/OIG (system number OIG-002) published in the Federal
Register (60 Fed. Reg. 19619, April 19, 1995) and incorporate by reference HHS system of
records number 09-90-0003 entitled Criminal Investigative Files of the Inspector General,
HHS/OS/OIG (55 Fed. Reg. 46248, Nov. 2, 1990) and HHS system of records number 09-900100 entitled Civil and Administrative Investigative Files of the Inspector General,
HHS/OS/OIG (47 Fed. Reg. 43190, Sept. 30, 1982). The relevant SSA System of Records is
System of Records Notice 60-0222, Master Representative Payee File, SSA/Office of Income
Security Programs.
Such routine uses include but are not limited to the following:
1) 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);

SSA Form 322

2) To make determination for eligibility in similar health and income maintenance
programs at the Federal, State, and local level;
3) To facilitate statistical research, audit or investigative activities necessary to assure
the integrity of Social Security programs; and,
4) To provide a claimant or other individual authorized to act on his/her behalf,
information pertaining to the address of a representative payee applicant or a selected
representative payee when this information is needed to pursue a claim for recovery
of misapplied or misused benefits.
5) To assist an appropriate law enforcement agency if we believe that the information
you provide alleges a criminal or civil violation properly within their jurisdiction.
We may also use the information you provide in computer matching programs pursuant to the
computer matching provisions of the Privacy Act of 1974, as amended (See 5 U.S.C. §
552a). Computer 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 or administered
benefit programs and for repayment of payments or delinquent debts under these programs.
A complete list of the permissible disclosures that the OIG and SSA may make of the
information that you provide is available in the aforementioned Systems of Records notices.
The Notice information about this form, and other information regarding the OIG’s and SSA’s
systems, programs and operations, is available on-line at www.socialsecurty.gov. Further,
information regarding SSA is also available at your local Social Security office.

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.

SSA Form 322

Beneficiary Information
Name:

SSN:

Age:

Beneficiary Interview (ask the beneficiary or if the beneficiary cannot respond ask the custodian
or caregiver the following questions)

1. Are you satisfied with the living arrangements provided by the representative payee?
Yes
No
If no, obtain the beneficiary’s explanation.

2. Are you satisfied with the clothing and personal items provided by the representative payee?
Yes
No
If no, obtain the beneficiary’s explanation.

SSA Form 322

3. Are you satisfied with the food provided by the representative payee?
Yes
No
If no, obtain the beneficiary’s explanation.

4. Does the representative payee pay your bills in a timely manner?
Yes
No
If no, obtain the beneficiary’s explanation.

5. Does the representative 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. Other comments or observations of the beneficiary.

Auditor’s Observations
1. Does the living quarters and housing appear to be adequate?
Yes
No
If no, explain.

2. Does the beneficiary’s wardrobe and clothes appear to be adequate?
Yes
No
If no, explain.

SSA Form 322

3. Does it appear that the beneficiary is provided adequate food and medicine (if applicable)?
Yes
No
If no, explain.

4. Did anything come to your attention to indicate the beneficiary’s needs were not being met?

Yes
No
If yes, explain.

SSA Form 322

SSA will insert the following revised Privacy Act Statement into the form at its next
scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
The Inspector General Act of 1978, as amended (5 U.S.C. App. 3), and Sections 205 and 1631 of the Social
Security Act, as amended (42 U.S.C. §§ 405 and 1383), authorize us to collect this information. The
information you provide will allow the Office of the Inspector General (OIG) and the Social Security
Administration (SSA) to ensure the integrity of the representative payee program and supplement other data
needed to determine whether representative payees are complying with their duties and responsibilities. The
information may also be used by SSA for the administration and integrity of its Social Security programs, and
disclosed by either the OIG and/or SSA to another person and/or to another agency/entity in accordance with
approved routine uses pertaining to the relevant Systems of Records to which any information that you provide
is incorporated.
Furnishing this information is voluntary and you will remain anonymous in any publicly issued OIG Audit
Reports. However, failing to provide all or part of the requested information could prevent SSA from making
an accurate and timely decision, or could result in the loss of benefits.
SSA and/or OIG routine uses permit disclosing the information you provide to another person or to another
agency in accordance with those 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 Social Security
benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level;
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under
contract with us); and
5. To assist an appropriate law enforcement agency if we believe that the information you provide
alleges a criminal or civil violation properly within their jurisdiction.
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. We use the information from
these programs to establish or verify a person’s eligibility for federally funded or administered benefit programs
and for repayment of incorrect payments or delinquent debts under these programs.
The relevant OIG Systems of Records are the Criminal Investigative Files of the Inspector General, SSA/OIG
(system number OIG-001) and the Civil and Administrative Investigative Files of the Inspector General,
SSA/OIG (system number OIG-002) published in the Federal Register (60 Fed. Reg. 19619, April 19, 1995) and
incorporate by reference HHS system of records number 09-90-0003 entitled Criminal Investigative Files of the
Inspector General, HHS/OS/OIG (55 Fed. Reg. 46248, Nov. 2, 1990) and HHS system of records number 0990-0100 entitled Civil and Administrative Investigative Files of the Inspector General, HHS/OS/OIG (47 Fed.

Reg. 43190, Sept. 30, 1982) The relevant SSA System of Records is System of Records Notice 60-0222,
Master Representative Payee File, SSA/Office of Income Security Programs.
These notices, additional information about this form, and other information regarding OIG’s and SSA’s
programs, systems, and operations, is available on-line at www.socialsecurity.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
Collection and Use of Personal Information
The Inspector General Act of 1978, as amended (5 U.S.C. App. 3), and Sections 205 and 1631 of the Social
Security Act, as amended (42 U.S.C. §§ 405 and 1383), authorize us to collect this information. The
information you provide will allow the Office of the Inspector General (OIG) and the Social Security
Administration (SSA) to ensure the integrity of the representative payee program and supplement other data
needed to determine whether representative payees are complying with their duties and responsibilities. The
information may also be used by SSA for the administration and integrity of its Social Security programs, and
disclosed by either the OIG and/or SSA to another person and/or to another agency/entity in accordance with
approved routine uses pertaining to the relevant Systems of Records to which any information that you provide
is incorporated.
Furnishing this information is voluntary and you will remain anonymous in any publicly issued OIG Audit
Reports. However, failing to provide all or part of the requested information could prevent SSA from making
an accurate and timely decision, or could result in the loss of benefits.
SSA and/or OIG routine uses permit disclosing the information you provide to another person or to another
agency in accordance with those 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 Social Security
benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level;
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under
contract with us); and
5. To assist an appropriate law enforcement agency if we believe that the information you provide
alleges a criminal or civil violation properly within their jurisdiction.
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. We use the information from
these programs to establish or verify a person’s eligibility for federally funded or administered benefit programs
and for repayment of incorrect payments or delinquent debts under these programs.
The relevant OIG Systems of Records are the Criminal Investigative Files of the Inspector General, SSA/OIG
(system number OIG-001) and the Civil and Administrative Investigative Files of the Inspector General,
SSA/OIG (system number OIG-002) published in the Federal Register (60 Fed. Reg. 19619, April 19, 1995) and
incorporate by reference HHS system of records number 09-90-0003 entitled Criminal Investigative Files of the
Inspector General, HHS/OS/OIG (55 Fed. Reg. 46248, Nov. 2, 1990) and HHS system of records number 0990-0100 entitled Civil and Administrative Investigative Files of the Inspector General, HHS/OS/OIG (47 Fed.
Reg. 43190, Sept. 30, 1982) The relevant SSA System of Records is System of Records Notice 60-0222,
Master Representative Payee File, SSA/Office of Income Security Programs.

These notices, additional information about this form, and other information regarding OIG’s and SSA’s
programs, systems, and operations, is available on-line at www.socialsecurity.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 (OMB) 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 21235-0001.