Application for Survivor's Benefits

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
Section 202(o) and 205(a) of the Social Security Act, as amended, allows 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 your claim or could result in
the loss of some benefits or insurance coverage.
We will use the information you provide to determine whether social security benefits may be
payable to a survivor of a veteran. We may also share this information for the following
purposes, called routine uses:
1. To third party contacts that may have information relevant to the Social Security
Administration's establishment or verification of information provided by representative
payees or payee; and
2. To Federal, State, or local agencies (or agents on their behalf) for administering income
maintenance or health maintenance programs (including programs under the Social
Security Act).
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 to 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),
60-0089, entitled Claims File System, and SORN 60-0090, entitled Master Beneficiary Record.
Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.