Non-Federal Employer Signers

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 3371 – 3375 of title 5 of the U.S. Code allow us to collect this information. Furnishing
us this information is voluntary. Failing to provide all or part of the information may result in
your ineligibility to participate in the Intergovernmental Personnel Act (IPA) Mobility Program.
We will use the information to document your IPA assignment. We may also share your
information for the following purposes, called routine uses:
1. To a Federal, State, or local agency maintaining civil, criminal or other relevant
enforcement records or other pertinent records, such as current licenses, if necessary to
obtain a record relevant to an Agency decision concerning the hiring or retention of an
employee, the issuance of a security clearance, the letting of a contract, or the issuance of
a license, grant or other benefit; and
2. To a Federal agency, in response to its request, in connection with the hiring or retention
of an employee, the issuance of a security clearance, the reporting of an investigation of
an employee, the letting of a contract, or the issuance of a license, grant or other benefit
by the requesting agency, to the extent that the record is relevant and necessary to the
requesting agency’s decision on the matter.
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 the U.S. Office of Personnel Management’s
(OPM) government-wide System of Records Notice (SORN) OPM/GOVT-1, entitled General
Personnel Records and in our Privacy Act SORN 60-0239, entitled Personnel Records in
Operating Offices. Additional information and a full listing of all our SORNs are available on
our website at www.socialsecurity.gov/foia/bluebook.