SSA-5665-BK (Electronic)

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 202, 221, 223, 1614(a), 1631(e), and 1633 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
the named claimant’s eligibility for benefits claim filed.
We will use the information you provide to make a determination of eligibility for benefits. We
may also share the 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 Social
Security Act; and

•

To Federal, State, or local agencies (or agents on their behalf), for administering
income or health maintenance programs including programs under the Social Security
Act.

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, Claims Folders System, as published in the Federal Register (FR) on October
31, 2019, at 84 FR 58422; and 60-0320, Electronic Disability (eDIB) Claim File, as published in
the FR on June 4, 2020, at 85 FR 34477. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy.

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
control number. We estimate that it will take about 40 minutes to read the instructions, gather
the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security
office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800772-1213 (TTY 1-800-325-0778). You may send comments regarding this burden estimate or
any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate
or other aspects of this collection to this address, not the completed form.