Form SSA-1699

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(a) 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 prevent you from serving as an appointed representative and receiving
your payments directly.
We will use the information you provide to register or appoint you as a representative and to
facilitate your direct payment of authorized fees. We may also share your information for the
following purposes, called routine uses:


To the IRS and to State and local government tax agencies in response to inquiries
regarding receipt of fees we paid directly starting in calendar year 2007; and



To contractors and other Federal agencies, as necessary, to assist us in efficiently
administering our programs.

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
(SORN) 60-0325, entitled Appointed Representative File, as published in the Federal Register
(FR) on October 08, 2009, at 74 FR 51940. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy.

5/29/2019 1:58 PM