Applicaiton To Collect A Fee For Payee Services (Private Sector Business)

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) and 1631(a) 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 us from authorizing your organization to become a fee-forservice representative payee.
We will use the information you provide to help us determine your organization’s eligibility as a
fee-for-service representative payee. We may also share the information for the following
purposes, called routine uses:
1. To a claimant or other individual authorized to act on his or her behalf information
concerning the status of his or her representative payee or the status of the application of
a person applying to be his or her representative payee, and information pertaining to the
address of a representative payee applicant or a selected representative payee when this
information is needed to pursue a claim for recovery of misapplied or misused benefits;
and
2. 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. Additional information and a full
listing of all our SORNs are available on our website at https://www.ssa.gov/privacy/sorn.html.

10/11/2017 9:35 AM