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Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 1611(c)(1), 1631(d) and (e)(1)(B) of the Social Security Act, as amended,
authorize us to collect this information. We will use the information you provide to help us
determine the individual’s eligibility for benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from making an accurate and timely decision on any claim for
benefits.
We rarely use the information you supply for any purpose other than to complete our claims
process. 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 complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notices 60-0040, entitled Quality Review
System, 60-0042, entitled Quality Review Case Files, and 60-0057, entitled Quality Evaluation
Data Records. Additional information about these 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 share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs 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.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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. The OMB control number for this information collection is 0960-0133. We
estimate that it will take about 30 minutes to read the instructions, gather the facts, and
answer the questions. Send only comments relating to our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.