Form SSA-9584-BK State Mental Instintution Policy Review

See below for revised Privacy Act and Paperwork Reduction Act Statements.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 1 hour
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 1800-325-0778). 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.

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(j)(3)(A) and 1631(a)(2)(C) of the Social Security Act, as amended, authorize us to
collect this information. The information you provide will be used to determine if the
beneficiary’s needs are being met.
The information you furnish on this form is voluntary. However, failure to provide all or part of
this information may result in the selection of another representative payee.
We rarely use the information you supply for any purpose other than for making a determination
about your continuing entitlement to benefits. 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 and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and 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 and improvement of Social Security programs (e.g., to the Bureau of the
Census and private concerns under contract to Social Security).
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 programs 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, Master Beneficiary Record, 60-0090 and Master Representative Payee File, 600222. These notices, additional information regarding this form, and information regarding our
programs and systems, are available on-line at www.socialsecurity.gov or at your local Social
Security office.