Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form

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 204, 1631(b), and 1879 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 could prevent us from making an accurate decision on your benefits.
We will use the information you provide to determine whether to waive overpayment recovery or
change your repayment rate. We may also share the information for the following purposes,
called routine uses:
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To employers to assist the Social Security Administration (SSA) in the collection of debts
owed by former beneficiaries and representative payees of Social Security payments who
received an overpayment and owe a delinquent debt to SSA; and
To third party contacts such as private collection agencies and credit reporting agencies
under contract with SSA and State motor vehicle agencies for the purpose of their
assisting SSA in recovering overpayments.

A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0090, entitled Master Beneficiary Record, as published in the Federal Register (FR)
on January 11, 2006, at 71 FR 1826; 60-0094, entitled Recovery of Overpayments, Accounting
and Reporting/Debt Management System, as published in the FR on August 23, 2005, at 70 FR
49354; and 60-0103, entitled Supplemental Security Income Record and Special Veterans
Benefits, as published in the FR on January 11, 2006, at 71 FR 1830. Additional information,
and a full listing of all our SORNs, is available on our website at www.ssa.gov/privacy.