Form SSA-1709 Request for Worker's Compensation/Public Disability Bene

See
Revised
Privacy
Act

See Revised
Paperwork
Reduction Act
Statement

The following revised Privacy Act Statement will be inserted into the form
at its next scheduled reprinting:
Privacy Act Statement
Collection of Use of Personal Information
Section 224 (42 U.S.C. 424) of the Social Security Act, as amended authorizes us to
collect this information. The information you provide is used to determine the effect of
the claimant’s workers’ compensation or public disability benefit, on his or her Social
Security disability insurance benefits. Your response is voluntary; however, failure to
provide all or part of the requested information could prevent an accurate and timely
decision on this claim.
We rarely use the information provided on this form for any other purpose other than for
the reasons explained above. 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 and improvement of Social Security Administration 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 the repayment of payments or delinquent debts under these programs.
A complete list of routines uses for this information is available in Systems of Records
Notice 60-0089. The notice, additional information regarding this form, and information
regarding our programs and systems, are available on-line at www.socialsecurity.gov or
at any U.S. Social Security office.

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 15
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.