Appointment of Representative

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 206 and 1631(d) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent us from appointing a representative to act on your behalf.
We will use the information to verify the appointment of your representative and his or her
acceptance of the appointment. We may also share your information for the following purposes,
called routine uses:
1. To a congressional office in response to an inquiry from that office made on behalf of,
and at the request of, the subject of the record or a third party acting on the subject’s
behalf.
2. To Federal, State, and local law enforcement agencies and private security contractors, as
appropriate, information necessary:
(a) to enable them to protect the safety of Social Security Administration (SSA)
employees and customers, the security of the SSA workplace, and the operation of
SSA facilities; or
(b) to assist investigations or prosecutions with respect to activities that affect
such safety and security or activities that disrupt the operation of SSA facilities;
and
3. To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA
in the efficient administration of its programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORNs) 60-0089, entitled Claims Folders Systems; 60-0320, entitled Electronic Disability
Claim File; and 60-0325, entitled Appointed Representative File. Additional information and a
full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.