Form SSA-322 Beneficiary Interview and Auditor's Observations

FORM APPROVED
OMB NO. 0960-0630

BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS

Privacy Act Statement

See Revised Privacy
Act Statement

The Inspector General Act of 1978, as amended, and Sections 205 and 1631 of the Social
Security Act, as amended, 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 OIG-001, Criminal Investigative Files of the Inspector
General, SSA/OIG and OIG-002, Civil and Administrative Investigative Files of the Inspector
General, SSA/OIG, 60 FR 19619 (April 19, 1995), 55 FR 46248 (November 2, 1990) and 47
FR 43190 (September 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);
2) To make determination for eligibility in similar health and income maintenance
programs at the Federal, State, and local level;

SSA Form 322

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. Computer
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. A complete list of the permissible
disclosures that the OIG and SSA may make of the information that you provide is available
in the above-referenced Systems of Record 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.
See Revised
Paperwork Reduction
Paperwork Reduction Act Statement
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

FORM APPROVED
OMB NO. 0960-0630

SSA will insert the following revised Privacy Act Statement into the form as soon as
possible:
BENEFICIARY INTERVIEW AND AUDITOR’S OBSERVATIONS

Privacy Act Statement
The Inspector General Act of 1978, as amended, and Sections 205 (j)(3)(A) and 1631
(a)(2)(C)(i) of the Social Security Act, as amended, 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 OIG-001, Criminal Investigative Files of the Inspector
General, SSA/OIG and OIG-002, Civil and Administrative Investigative Files of the Inspector
General, SSA/OIG, 60 FR 19619 (April 19, 1995), 55 FR 46248 (November 2, 1990) and 47
FR 43190 (September 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);
2) To make determination for eligibility in similar health and income maintenance
programs at the Federal, State, and local level;

SSA Form 322

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. Computer
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. A complete list of the permissible
disclosures that the OIG and SSA may make of the information that you provide is available
in the above-referenced Systems of Record 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.socialsecurity.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

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