Ssa-2854

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

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 may prevent
us from making an accurate and timely decision in your eligibility for Supplemental Security
Income (SSI) benefits.
We will use the information you provide to help us determine eligibility for benefits. We may
also share your information for the following purposes, called routine uses:
•

To the following Federal and State agencies to prepare information for verification of
benefit eligibility under section 1631(e) of the Social Security Act: Bureau of Indian
Affairs; Office of Personnel Management; Department of Agriculture; Department of
Labor; U.S. Citizenship and Immigration Services; Internal Revenue Service;
Railroad Retirement Board; State Pension Funds; State Welfare Offices; State
Worker's Compensation; Department of Defense; United States Coast Guard; and
Department of Veterans Affairs; and

•

To contractors and other Federal Agencies, as necessary, for the purpose of assisting
us in the efficient administration of our programs. We will disclose information
under this routine use only in situations in which we may enter into a contractual or
similar agreement to obtain assistance in accomplishing an SSA function relating to
this system of records.

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
October 31, 2019, at 84 FR 58422, 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.

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
(OMB) control number. We estimate that it will take about 15 minutes to read the instructions,
gather the facts, and answer the questions. Send only 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.