SSA-6234: Representative Payee Report (Organization)

SSA will insert the following revised Privacy Act and PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205 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 result in a delay in ensuring you are using the money you receive from us
for the beneficiary’s benefit.
We will use the information to ensure the beneficiary’s payments are being properly used and
managed. We may also share your information for the following purposes, called routine uses:
1. To third party contacts that may have information relevant to the Social Security
Administration's establishment or verification of information provided by representative
payees or payee applicants.
2. 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
3. To a claimant or other individual authorized to act on his or her behalf information
concerning the status of his or her representative payee or the status of the application of
a person applying to be his or her representative payee, and information pertaining to the
address of a representative payee applicant or a selected representative payee when this
information is needed to pursue a claim for recovery of misapplied or misused benefits.
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) 60-0090, entitled Master Beneficiary Record; 60-0103, entitled Supplemental Security
Income Record and Special Veterans Benefits; and 60-0222, entitled Master Representative
Payee File. Additional information and a full listing of all our SORNs are available on our
website at www.socialsecurity.gov/foia/bluebook.

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 15 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments relating to our
time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.