Statement of Income and Resources

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 1612(a), 1613(a), 1614(f), 1621, and 1631(e) 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
the claim filed.
We will use the information to make an initial or continuing Supplemental Security Income (SSI)
eligibility determination. We may also share your information for the following purposes, called
routine uses:
1. To State agencies to enable them to assist in the effective and efficient administration of
the SSI program; and
2. To representative payees, when the information pertains to individuals for whom they
serve as representative payees, for the purpose of assisting the Social Security
Administration in administering its representative payment responsibilities under the
Social Security Act 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.
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.
Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.