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 and 205 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 decision on your claim.
We will use the information to make a decision regarding continuing entitlement to benefits. We
may also share your information for the following purposes, called routine uses:
1. To third party contacts in situations where the party to be contacted has, or is expected to
have, information relating to an individual’s capability to manage his/her affairs or
his/her eligibility for or entitlement to benefits under the Social Security program when
the individual is unable to provide the information being sought;
2. To third party contacts where necessary to establish or verify information provided by
representative payees or payee applicants; and
3. To the Department of State and its agents for administering the Act in foreign countries
through facilities and services of that agency.
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
(SORNs) 60-0089, entitled Claims Folders Systems. Additional information and a full listing of
all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.