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 (OMB) control number. We estimate that it will take about 10 minutes to read the instructions, gather
the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.
Form SSA-788 (01-2015) UF (01-2015) Page 3
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 205(j) of the Social Security Act, as amended, authorize us to collect this information. We will use the
information you provide to help us establish your suitability to serve as a representative payee.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information could prevent us from
making a decision to select you as a representative payee.
We rarely use the information you supply for any purpose other than for establishing payee suitability. 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 assure the integrity and improvement of
Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).
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.
A complete list of routine uses for this information is available in Systems of Records Notice entitled, Master Representative
Payee File, 60-0222. This notice, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.
Paperwork Reduction Act Statement -
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly
gives a false or misleading statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be sent to prison, or may face other penalties, or both.
SIGNATURE OF PERSON MAKING STATEMENT
SIGNATURE (First name, middle initial, last name) (Write in ink)
DATE (Month, day, year)
SIGN
HERE
Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the individual must sign below, giving their full address.
1. SIGNATURE OF WITNESS
ADDRESS (No. & Street, City, State, and ZIP Code)
ADDRESS (No. & Street, City, State, and ZIP Code)
TELEPHONE NUMBER (Include area code)
MAILING ADDRESS (Number and street, Apt. No., P.O. Box, or Rural Route)
CITY AND STATE ZIP CODE NAME OF COUNTY (IF ANY)
2. SIGNATURE OF WITNESS
