Representative Payee Report of Benefits and Dedicated Account, 20 CFR 416.546 & 640, and 20 CFR 416.635 & 665

SSA will insert the following revised Privacy Act and PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205and 1631(a) of the Social Security Act, as amended, allow us to collect this
information. We will use the information you provide to account for the beneficiary's payments
and ensure the payments are meeting the beneficiary’s needs.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may ultimately prevent you from serving as a representative payee.
We rarely use the information you supply for any purpose other than what we state above,
however, we may use the information for the administration of our programs including sharing
information:
1. 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);
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us); and,
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0222, entitled Master Representative
Payee File. Additional information about this and other system of records notices and our
programs is available from our Internet website at www.socialsecurity.gov or at your local Social
Security office.
We may share 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.
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 20 minutes to read the instructions, gather
the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security
office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800772-1213 (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.