SSA-7161-OCR-SM--Report to U.S. SSA by Person Receiving Benefits for a Child or Adult Unable to Handle Funds

Form SSA-7161-INST (04-2011) Destroy Prior Editions

PRIVACY ACT STATEMENT- Collection and Use of
Personal Information--The United States Code of Federal
regulations (42 U.S.C. § 403(c), 403(g), 405(a) and 405(j))
authorize us to collect the information on this form. The
information you provide will be used to determine if we can
continue to pay Social Security benefits on this claim.
Your response is voluntary. However, failure to provide
the requested information may prevent us from making an
accurate and timely decision, or could result in the loss of
benefits.

See Revised Privacy Act Statement Attached

We rarely use the information provided on this form for any
purpose other than for determining the continued entitlement to benefit payments. However, in accordance with 5
U.S.C. § 552a(b) of the Privacy Act, we may disclose the
information provided on this form (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
make determinations for eligibility in similar health and
income maintenance programs at the Federal, State, and
local level; (3) to comply with Federal laws requiring the
disclosure of the information from our records; and (4) to
facilitate statistical research, audit or investigative activities necessary to assure the integrity of SSA programs.
We may also use the information you provide when we
match records by computer. Computer matching programs
compare our records with those of 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
contained in our System of Records Notice 60-0089
(Claims Folders System). Additional information regarding this form and our other system of records notices and
Social Security programs are available from our Internet
website at www.socialsecurity.gov or at
any U.S.
Embassy, consulate, VARO or Social Security office.

Form SSA-7161-INST (04-2011) Destroy Prior Editions

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 203, 205, and 1631 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 an accurate and timely decision on any claim filed.
We will use the information to determine continued eligibility for benefits and to monitor
representative payee performance. We may also share your information for the following
purposes, called routine uses:
•

To Department of State and its agents for administering the Social Security Act in foreign
countries through facilities and services of that agency; and

•

To agencies or entities with responsibility for investigating or addressing possible
financial exploitation of, an immediate health or safety threat to, or other serious risk to
the well-being of the beneficiary, for referral, when these issues are identified during a
representative payee review.

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) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784, and 60-0320, entitled Electronic Disability Claim File, as
published in the FR on December 22, 2003, at 68 FR 71210. Additional information, and a full
listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.