Form SSA-824 Report on Individual with Mental Impairment

See Revised PRA Attached

See Revised Privacy Act Notice

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 36
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.

The following revised Privacy Act Statement will be inserted into the form at its next
scheduled reprinting:
Privacy Act Notice: Sections 205(a), 223(d) and 1631(e)(1) of the Social Security Act, as amended,
authorize us to collect this information. The information is needed to determine benefit eligibility of the
named claimant. The information you furnish on this form is voluntary. However, failure to provide all or
part of the information could prevent an accurate and timely decision on benefit eligibility of the named
claimant.
We rarely use the information you supply for any purpose other than for establishing benefit eligibility.
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: (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; (4) to private medical and vocational
consultants for use in consultative medical examinations or vocational assessments; (5) to State vocational
rehabilitation agencies or State agencies or other agencies providing services to disabled children; and (6)
to facilitate statistical research, audit or investigative activities necessary to assure 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
and 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 System of Records Notices 60-0044, 600089, 60-0320. The notices, additional information regarding this form, and information regarding our
programs and systems, are available on-line at www.ssa.gov or at your local Social Security office.