Request for Waiver of Special Veterans Benefits (SVB) Overpayment Recovery or Change in Repayment Rate

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 808 and 1147 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 affect your benefits.
We will use the information to make a determination on your overpayment waiver request or
change your monthly repayment rate. We may also share your information for the following
purposes, called routine uses:
1. To representative payees, when the information pertains to individuals for whom they
serve as representative payees, for the purpose of assisting SSA in administering its
representative payment responsibilities under title VIII and assisting the representative
payees in performing their duties as payees, including receiving and accounting for
benefits for individuals for whom they serve as payees; and
2. To third party contacts (including private collection agencies under contract with SSA)
for the purpose of their assisting SSA in recovering overpayment.
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) 60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits,
and 60-0273, entitled Social Security Title VIII Special Veterans Benefits Claims Development
and Management Information System. Additional information and a full listing of all our
SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.