Application for Child's Insurance Benefits / Death Claim / SSA-4-BK

Form SSA-4-INST (01-2017) UF

Page 2 of 2

NOTICE ABOUT DOCUMENTS
We recommend that you keep copies of all documents you submitted to us.

D We are returning the documents you submitted with this claim.

See Revised Privacy Act
Statement

Privacy Act Statement
Collection and Use of Personal Information

Sections 202, 205, 223, 1818, 1836, and 1840 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 any claim filed, or could result in the loss of
benefits.
We will use the information you provide to determine eligibility for monthly benefits or insurance coverage
and to authorize payments to the children of retired, disabled, or deceased workers. We may also share
your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies (or agents on their behalf) for administering cash or non-cash
income maintenance or health maintenance programs (including programs under the Act).
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the
efficient administration of its programs. We contemplate disclosing information under this routine
use only in situations in which SSA may enter a contractual or similar agreement with a third party
to assist in accomplishing an agency function relating to this system of records.
3. 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.
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) 60-0089,
entitled Claims Folder System, and 60-0321, entitled Medicare Database (MOB) File. Additional information
and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.
Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to
answer these questions unless we display a valid Office of Management and Budget (0MB) control number.
We estimate that it will take about 12 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.

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(d) 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 any claim filed.
We will use the information to determine eligibility for monthly benefits or insurance coverage
and to authorize payments to the child(ren) of retired, disabled, or deceased workers. We may
also share your information for the following purposes, called routine uses:
•

To Federal, State, or local agencies for administering cash or non-cash income or health
maintenance programs; and

•

To a contractor or another Federal agency, as necessary for the purpose of assisting the
Social Security Administration in the efficient administration of its programs.

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) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784. Additional information, and a full listing of all of our SORNs, is
available on our website at www.ssa.gov/privacy.