Form Ssa-11-Bk - Request To Be Selected As Payee - 2009 Page 10

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A REMINDER TO PAYEE APPLICANTS
BEFORE YOU RECEIVE A
SSA OFFICE
DATE REQUEST RECEIVED
DECISION NOTICE
TELEPHONE NUMBER(S)
TO CALL IF YOU HAVE A
QUESTION OR SOMETHING
AFTER YOU RECEIVE A
TO REPORT
DECISION NOTICE
RECEIPT FOR YOUR REQUEST
Your request for Special benefits for WW II Veterans on
you — or someone for you — should report the change.
behalf of the individual(s) named below has been received
The changes to be reported are listed on the reverse.
and will be processed as quickly as possible.
You should hear from us within
days after you have
Always give us the claim number of the beneficiary when
given us all the information we requested. Some claims
writing or telephoning about the claim.
may take longer if additional information is needed.
In the meantime, if you change your address, or if there is
If you have any questions about this application, we will
some other change that may affect the benefits payable,
be glad to help you.
BENEFICIARY
SOCIAL SECURITY CLAIM NUMBER
THE PRIVACY ACT
Sections 205(a) and 205(j) of the Social Security Act, as amended, authorize us to collect the information on this form. The information
you provide will be used to determine if you are qualified to serve as a representative payee. Your response is voluntary. However,
failure to provide the requested information will prevent us from making a determination to select you as representative payee.
We rarely use the information provided on this form for any purpose other than for making representative payee selections. 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 evaluating payee applicants' suitability to be named representative payees; (2) to claimants or
other individuals when needed to pursue a claim for recovery of misapplied or misused benefits; (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. The law allows us to do this even if you do not agree to it.
A complete list of routine uses for this information is contained in our System of Records Notice 60-0222 (Master Representative Payee
File). Additional information regarding this form and our other systems of records notices and Social Security programs are available from
our Internet website at or at your local Social Security office.
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 10.5 minutes to read the instructions, gather the facts, and answer the
questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (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.
Form SSA-11-BK (08-2009)
EF (08-2009)
Page 10

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