Statement of Care and Responsibility for Beneficiary

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 205(j), 807, & 1631(a)(2) of the Social Security Act, as amended, allows us to collect this information.  Furnishing us this information is voluntary.  However, failing to provide all or part of the information may prevent your selection as a representative payee.

We will use the information you provide to establish payee suitability. We may also share your information for the following purposes, called routine uses:

• To a third party, where necessary, information pertaining to the identity of a representative payee or representative payees applicant, the fact of the person’s application for or service as a representative payee, and, as necessary, the identity of the beneficiary, to obtain information on employment, sources of income, criminal justice records, stability of residence, and other information relating to the qualifications sand suitability of representative payees or representative payee applicants to serve as representative payees, or their use of the benefits paid to them under sections 205(j), 807, or 1631(a) of the Social Security Act; and

• To third parties, contractors, or other Federal agencies, as necessary, to conduct criminal background checks and to obtain criminal history information on representative payees and representative payee applicants.

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) 60-0222, entitled Master Representative Payee File, as published in the Federal Register (FR) on November 2, 2018 at 83 FR 55228.  Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.