Financial Disclosure for Civil Monetary Penalty (CMP) Debt

SSA will insert the following revised Privacy Act and PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 204 (a) and 1129, of the Social Security Act, as amended, and the Inspector General Act
of 1978, as amended (5 U.S.C. App. 3), authorizes the collection of the information on this form.
We will use the information you provide to make a determination regarding the payment of your
Civil Monetary Penalty (CMP) debt.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on your request.
We rarely use the information you supply us for any purpose other than to recover your CMP
debt. However, we may use the information for the administration of Social Security programs
including sharing information:
1. 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); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of Social Security programs (e.g., to the Bureau of the Census
and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notices 60-0094, entitled Recovery of Overpayments,
Accounting and Reporting/Debt Management System (ROAR/DMS) and the Social Security
Administration (SSA), Office of the Inspector General’s System of Records Notice OIG-002,
entitled Civil and Administrative Investigative Files of the Inspector General, SSA/OIG (60 Fed.
Reg. 19619, April 19, 1995, duplicating and incorporating by reference HHS system of records
number 09-90-0100, entitled Civil and Administrative Investigative Files of the Inspector
General, HHS/OS/OIG (47 Fed. Reg. 43190, September 30, 1982). Additional information
about these and other system of records notices and our programs are available online at
www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching
programs compare our records or those of the SSA’s Office of the Inspector General 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 incorrect payments or delinquent debts
under these programs.