Advance Designation of Representative Payee (Internet Version - iClaim)

Advance Designation – “Yes, Provide AD Now”
(Screen split into 3 images below)

Providing “relationship” is optional, but the user must provide an answer to this field. “No
response” is an option to select if the user does not want to provide relationship.

Advance Designation – *“Restart – AD No Longer Applies”

Overall Summary – “No, Do Not Provide AD Now”

Overall Summary– “Yes, Provide AD Now”

Overall Summary – *“Restart – AD No Longer Applies”

* “Restart – AD No Longer Applies” screen provides information to an iClaim user in the
following possible scenario:
•
•
•

The iClaim user is eligible to see the Advance Designation option screens when
completing the iClaim, but leaves the claim without submitting it.
Upon re-entry into iClaim, the iClaim user now has a representative payee and is no
longer eligible to see the Advance Designation option screens.
iClaim will remove the Advance Designation option screens, along with any information
previously input by the filer, and will display this screen instead. The language on this
screen is intentionally broad because iClaim is not allowed to disclose information from
our records to the iClaim user, including the presence of a newly selected representative
payee.

The final screens in the mock-up show how the responses will display in the iClaim summary,
where the applicant will sign. The iClaim receipt is the same screen as the summary, but
without the signature agreement.

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

Section 205(j) of the Social Security Act, as amended, allows 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 selecting the representative payee(s) you designate to act
on your behalf.
We will use the information you provide to update and maintain your representative payee(s).
We may also share the information for the following purposes, called routine uses:
•

To third party contacts, where necessary, to establish or verify information provided
by representative payees or representative payee applicants; and

•

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

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(s)
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
October 31, 2019, at 84 FR 58422. Additional information, and a full listing of all 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 6 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.