This online service allows you to electronically complete, sign, and submit the Dedicated Account Use of Funds Statement (Form SSA-552). You may use this online service as an alternative to completing a paper version of this form. To complete the form online, you will need a valid email address.

Before beginning the form, you will need to enter and confirm your email address in the online application.

You will receive an email from adobesign@adobesign.com containing a link and instructions on how to access the form. The link will expire after five (5) calendar days. If the link expires, you will need to return to this page to request a new link.

IMPORTANT: We will not process the form until you complete the form, sign the form electronically, and select “Click to Sign” to submit the form. Upon submission, you will be able to download a copy of the signed form within the application. We recommend that you save a copy for your records. You will receive an email confirming your submission.

PLEASE NOTE:

This website is most compatible with Microsoft Edge and Google Chrome.
The form must be electronically completed, signed, and submitted in a single session.
The system will end your session after 60 minutes of inactivity and no information will be saved.
A daily email reminder will be sent for five (5) days or until the form has been submitted.
If you do not receive an email notification within a few minutes of your online submission, be sure to check your email’s junk folder.

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 or delay entitlement payments from being deposited into a dedicated account.

We will use the information you provide to confirm your understanding of use restrictions associated with the dedicated account. We may also share your information for the following purposes, called routine uses:

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
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.