SSA-21 - U.S. Residents, Paper Version

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 202(t), 203, 205, and 1838(b) of the Social Security Act and sections 871(a)(3) and
1441 of the Internal Revenue Code, 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 us from making an accurate and timely decision on any claim filed or could result in the
loss of benefits.
We will use the information to determine eligibility for benefits. We also use the form to
determine nonresident alien tax withholding status. We may also share your information for the
following purposes, called routine uses:
1. To contractors and other Federal agencies, as necessary, for the purpose of assisting
SSA in the efficient administration of its programs. We will disclose information
under this routine use only in situations in which SSA may enter into a contractual or
similar agreement with a third party to assist in accomplishing an agency function
relating to this system of records; and
2. To the Centers for Medicare & Medicaid Services, for the purpose of administering
Medicare Part A, Part B, Medicare Advantage Part C, and Medicare Part D, including
but not limited to: Medicare Part C enrollment and premium collection processes;
Part D enrollment and premium collection processes; Medicare Part B premium
reduction based on participation in a Part C plan and Medicare Part B enrollment and
income-related monthly adjustment amount determinations, appeals of
determinations, and premium collection.
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 Notices
(SORN) 60-0089, entitled Claims Folders System, 60-0090, entitled Master Beneficiary Record,
and 60-0321, entitled Medicare Database. Additional information and a full listing of all our
SORNs are available on our website at www.ssa.gov/privacy/sorn.html.