Fee Agreement for Representation before the Social Security Administration

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 206 and 1631(d) 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 affect the amount of fees authorized for services rendered before us.
We will use the information to authorize fees for services rendered to the claimant named on the
form. We may also share the information for the following purposes, called routine uses:


To a claimant’s representative to the extent necessary to dispose of a fee petition or fee
agreement; except for pre-decisional deliberative documents, such as analyses and
recommendations prepared for the decision-maker;



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



To the Internal Revenue Service and to State and local government tax agencies in
response to inquiries regarding receipt of fees we paid directly starting in calendar year
2007.

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) 60-0003, entitled Attorney Fee File, as published in the Federal Register (FR) on
January 11, 2006, at 71 FR 1803; 60-0089, entitled Claims Folders Systems, as published in the
FR on April 1, 2003, at 68 FR 15784; and 60-0325, entitled Appointed Representative File, as
published in the FR on October 8, 2009, at 74 FR 51940. Additional information and a full
listing of all our SORNs are available on our website at www.ssa.gov/privacy.