Statement of Living Arrangements, In-Kind Support and Maintenance

SSA will insert the following revised Privacy Statement into the form as soon as possible:

Privacy Act Statement
Collection and Use of Personal Information

Sections 1612(a) and 1631(e) 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 us from making an accurate and timely decision on your eligibility for benefits.

We will use the information to determine benefit amounts based on your housing and living needs. We may also share your information for the following purposes, called routine uses:

• To third party contacts (e.g., employers and private pension plan) in situations where the party to be contacted has, or is expected to have, information relating to the individual's capability to manage his/her affairs or his/her eligibility for, or entitlement to, benefits under the Social Security program; and

• 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.

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) 60-0090, entitled Master Beneficiary Record, as published in the Federal Register (FR) on January 11, 2006 at 71 FR 1826; and 60-0103, entitled Supplementary Security Income Record, 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/.