Individuals/Households: Paper SSA-11-BK

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(a), 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 prevent an accurate and timely decision on your request for selection as a representative payee.

We will use the information to determine your eligibility to serve as a representative payee. We may also share your information for the following purposes, called routine uses:

• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA) in the efficient administration of its programs;

• To agencies or entities who have a written agreement with SSA, to perform reviews of the representative payee program and to provide training, administrative oversight, technical assistance, and other support for the program review; and

• To third parties, contractors, or other Federal agencies, as necessary, to conduct criminal background checks and to obtain criminal history information on representative payees and representative payee applicants.

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 (SORN) 60-0089 entitled Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784; 60-0222, entitled Master Representative Payee File, as published in the FR on November 2, 2018, at 83 FR 55228; and 60-0320, entitled Electronic Disability Claim File, as published in the FR on December 22, 2003, at 68 FR 71210. Additional information, and a full listing of all our SORNs, is available on our website at www.ssa.gov/privacy.