Non-Attorney Representative Demonstration Project - Paper Application

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

Section 206(e) 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 result in a determination that you are ineligible to receive direct payment of
fees.
We will use the information to help us determine your eligibility to receive direct payment of
representative fees. We may also share your information for the following purposes, called
routine uses:
1. To contractors and other Federal agencies, as necessary, to assist us in efficiently
administering our programs. We will disclose information under this routine use only in
situations in which we may enter into a contractual or similar agreement with a third
party to assist in accomplishing an agency function relating to this system of records; and
2. To student volunteers, persons working under a personal services contract, and others
who are not technically Federal employees, when they are performing work for us, as
authorized by law, and they need access to information in our records in order to perform
their assigned duties.
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. Additional information and a full
listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.