SSA-21 - Resident of Tax Treaty Country, Paper Version

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

Sections 202(t), 203, 205, and 1836(b) of the Social Security Act and sections 871(a)(3) and 1441 of the Internal Revenue Code, as amended, allow 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 on any claim filed or could result in the loss of benefits.

We will use the information you provide to determine eligibility for benefits. We may also share your information for the following purposes, called routine uses:

• To the IRS, Department of the Treasury, for the purpose of auditing SSA’s compliance with the safeguard provisions of the IRC of 1986, as amended; and

• To the Centers for Medicare & Medicaid Services (CMS), for the purpose of administering Medicare Part D enrollment and premium collection and Medicare Advantage Part C premium collections, as well as Medicare Part B income-related monthly adjustment amounts; and

• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA) in the efficient administration of its programs. We will disclose information under the routine use only in situations in which SSA may enter into a contractual or similar agreement with a third party to assist in accomplishing an agency 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 Notices (SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422, 60-0090, entitled Master Beneficiary Record, as published in the FR on January 11, 2006 at 71 FR 1826; and 60-0321, entitled Medicare Database File, as published in the FR on July 25, 2006, at 71 FR 42159. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.