SSA-1724 - Revised PA and PRA Statements

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

Sections 204(d) and 1870(g) 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 proper payment of a Title II underpayment or Medicare premium
refund due a deceased beneficiary.
We will use the information you provide to determine your eligibility for payment of a Title II
underpayment or Medicare premium refund due a deceased beneficiary. We may also share your
information for the following purposes, called routine uses:
•

To the Department of the Treasury, for: (a) Collecting Social Security taxes or as
otherwise pertinent to tax and benefit payment provisions of the Social Security Act,
including SSN verification services; and (b) investigating alleged theft, forgery, or
unlawful negotiation of Social Security checks; 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 Notices
(SORNs) 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 (MDB)
File, as published in the FR on July 25, 2006, at 71 FR 42159. Additional information, and a full
listing of all 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 10 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.