Ssa-1003-f3

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 205(a) and 205(c)(2)(A) 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 give the employee credit for the correct amount of wages earned.
We may also share the information for the following purposes, called routine uses:
1. To employers or former employers, including State Social Security administrators, for
correcting and reconstructing State employee earnings records and for Social Security
purposes; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA
in the efficient administration of its programs. We will disclose information under this
routine use only in situations in which SSA may enter into a contractual or similar
agreement with a third party to assist in accomplishing an agency function relating to this
system of records.
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 Notice
(SORN) 60-0059, entitled Earnings Recordings and Self-Employment Income System.
Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.