Representative Payee Evaluation Report--Individuals/Households

SSA will insert the following revised Privacy Act and PRA Statements 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 result in the termination of your status as representative payee.
We will use the information to determine your suitability to serve as a representative payee and
to ensure the representative payee is meeting the beneficiary’s needs. We may also share your
information for the following purposes, called routine uses:
•

To state protection and advocacy systems, that have a written agreement with Social
Security Administration to conduct reviews of representative payees, for the purpose of
conducting additional reviews that the protection and advocacy systems have reason to
believe are warranted; 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) 60-0222, 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 our
SORNs, is available on our website at www.ssa.gov/privacy.
Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take about 30 minutes to read the instructions, gather
the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security
office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.