Form SSA-11-BK Request to be Selected as Payee

see Revised Privacy Act Statement Attached

see Revised PRA Statement Attached

see Revised Privacy Act Statement Attached

see Revised PRA Statement Attached

see Revised Privacy Act Statement Attached

see Revised PRA Statement Attached

SSA will insert the following revised Privacy Act and PRA Statements into the form at
its next scheduled reprinting:
Request to Be Selected as Payee, form SSA-11-BK
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a) and (j) of the Social Security Act as amended, [42 U.S.C. 405(a) and (j)]
authorize us to collect this information. We will use the information you provide to help
us determine if you are qualified to serve as a representative payee. The information you
provide on this form is voluntary. However, failure to provide the requested information
may prevent us from making a determination to select you as a representative payee.
We rarely use the information you provide on this form for any purpose other than for the
reasons explained above. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not
limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records to other agencies (e.g., to the Government Accountability
Office, General Services Administration, National Archives Records
Administration, and the Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by other Federal, State, or
local government agencies. Information from these matching agencies can be used to
establish or verify a person’s eligibility for Federally-funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records
Notices entitled, Claims Folder System, 60-0089 and Master Representative Payee File,
60-0222. The notices, additional information regarding this form, and information
regarding our system and programs, are available on-line at www.socialsecurity.gov or at
any local Social Security office.

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 control number. We estimate that it will take about 10.5
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website
at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies
in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY
1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.