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 Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(j) and 1631(a) 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 result in the termination of benefits or payments.
We will use the information to account for the use of benefits and payments and ensure the
beneficiary’s needs are met. We may also share your information for the following purposes,
called routine uses:


To a claimant, or other individual authorized to act on his or her behalf, information
concerning the status of his or her representative payee or the status of the application of
a person applying to be his or her representative payee, and 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;
and



To agencies or entities with responsibility for investigating or addressing possible
financial exploitation of, an immediate health or safety threat to, or other serious risk to
the well-being of the beneficiary, for referral, when these issues are identified during a
representative payee review.

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 Notice
(SORN) 60-0222, entitled Master Representative Payee File, as published in the Federal Register
(FR) on April 22, 2013, at 78 FR 23811, and subsequently modified on July 3, 2018, at 83 FR
31251. Additional information, and a full listing of all our SORNs, is available on our website at
www.ssa.gov/privacy.