Form SSA-8019-U2 Third Party Liability Information Statement

Revised/updated penalty
language, see addendum for old
language.

See revised
Paperwork
Reduction Act and
Privacy Act
Statements below.

Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 1631(d)(1) and 1631(e)(1) of the Social Security Act (42 U.S.C. § 404), as
amended, authorize us to collect this information. We will use the information you provide to
assist us in making a decision on your claim.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent us from making an accurate decision on your claim.
We rarely use the information you supply for any purpose other than the reason stated 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 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 our System of Records Notices
entitled, Master Files of Social Security Number (SSN) Holders and SSN Applications System,
60-0058; Claims Folders Systems, 60-0089; and Master Beneficiary Record, 60-0090. These
notices, additional information regarding this form, and information regarding our systems and
programs, are available on-line at www.socialsecurity.gov or at any local 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 5
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.