Expanded Monitoring Site Review: Beneficiary Interview Form

SSA will insert the following revised Privacy Act & PRA Statements 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 prevent an accurate decision on the performance of the representative
payee and benefit payments may be affected.
We will use the information you provide to assist us in the monitoring the representative payee’s
performance. We may also share the information for the following purposes, called routine uses:
•

To contractors and other Federal Agencies, as necessary, for the purpose of assisting the
SSA in the efficient administration of its programs. We will disclose information under
this routine use only in situations in which SSA may enter into a contractual or similar
agreement to obtain assistance in accomplishing an SSA function relating to this system
of records; and

•

To a third party, where necessary, information pertaining to the identity of a
representative payee or representative payee applicant, the fact of the person’s application
for or service as a representative payee, and, as necessary, the identity of the beneficiary,
to obtain information on employment, sources of income, criminal justice records,
stability of residence, and other information relating to the qualifications and suitability
of representative payees or representative payee applicants to serve as representative
payees, or their use of the benefits paid to them under sections 205(j), 807, or 1631 (a) of
the Social Security Act.

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 November 2, 2018, at 83 FR 55228. Additional information, and a full listing of all of
our SORNs, is available on our website at www.ssa.gov/privacy.

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
(OMB) control number. We estimate that it will take about 10 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.