Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)

SSA will insert the following revised Privacy Act Statement into the form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 1614(a)(3) and 1631(e)(1) of the Social Security Act, as amended, allow us to collect
this information. Furnishing us this information is voluntary. However, failing to provide all or
part of the information may prevent an accurate and timely decision on any claim filed.
We will use the information to make a determination of eligibility for Supplemental Security
Income benefits. We may also share your information for the following purposes, called routine
uses:
1. To Federal, State, or local agencies for administering cash or non-cash income
maintenance or health maintenance programs;
2. To appropriate State agencies, or other agencies providing services to disabled children,
to identify Title XVI eligibles under the age of 16 for the consideration of rehabilitation
services; and
3. To specified business and other community members and Federal, State, and local
agencies for verification of eligibility for benefits.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORNs) 60-0089, entitled Claims Folders Systems; 60-0103, entitled Supplemental Security
Income Record and Special Veterans Benefits; and 60-0320, entitled Electronic Disability
(eDIB) Claim File. Additional information and a full listing of all our SORNs are available on
our website at www.socialsecurity.gov/foia/bluebook.