Application for Supplemental Security Income

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 1631(e) 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 Supplemental Security Income (SSI)
payments. We may also share your information for the following purposes, called routine uses:
•

To specified business and other community members and Federal, State, and local
agencies for verification of eligibility for benefits under section 1631(e) of the Act; and

•

To State agencies to enable them to assist in the effective and efficient administration of
the SSI program.

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 Systems, as published in the Federal Register (FR) on
April 01, 2003, at 68 FR 15784, 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 of our SORNs, is available on our website at
www.ssa.gov/privacy.