Form SSA-8202-BK Statement for Determining Continuing Eligibility Supplem

See Revised PRA Statement Attached

See Revised Privacy Act Statement Attached

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
Section 1611(c) of the Social Security Act, as amended, allows us to collect this
information. We will use the information you provide to attempt to determine if you
continue to be eligible for supplemental security income payments.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from making an accurate decision on your continuing
eligibility for benefits and could result in the loss of benefits.
We rarely use the information you supply for any purpose other than what we state
above, however, we may use the information for the administration of our programs,
including sharing information:
1. To comply with Federal laws requiring the release of information from our
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 our 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, 60-0103, entitled Supplemental
Security Income Record and Special Veterans Benefits System. Additional information
about this and other system of records notices and our programs is available from our
Internet website 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 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.
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 21
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in

your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.