Form Ssa-1699 - Registration For Appointed Representative Services And Direct Payment Page 2
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8Privacy Act Statement
Collection and Use of Personal Information
Sections 206(a) and 1631(d) of the Social Security Act, as amended, authorize us to collect this information. The
information. We will use the information you provide to facilitate direct payment of authorized fees and to meet the
reporting requirements of the law.
The information you furnish on this form is voluntary. However, failure to provide the requested information will prevent
you from serving as an appointed representative.
We generally use the information you supply for the purpose of facilitating payments. However, we may use it for the
administration and integrity of Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not limited to the following:
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 comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veterans' Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State,
and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to ensure the integrity of Social Security
programs.
We may also use the information you provide in computer matching programs. Matching programs compare our records
with records kept by 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.
Additional information regarding this form, routine uses of information, and our programs and systems, is available on-line
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 20 minutes to read the instructions, gather the facts, and answer the
questions. You may send comments on our time estimate, not the completed form, to SSA, 6401 Security Boulevard,
Baltimore, MD, 21235-6401
Form SSA-1699 (09-2013)
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