Revised PA & PRA Statements

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 224 (42 USC 424a) of the Social Security Act allows 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 a timely and accurate decision on this claim and could
affect the claimant’s benefits.
We will use the information to determine the effect of the claimant’s workers’ compensation or
public disability benefit on their Social Security disability insurance benefits.
We may also share your 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 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. Such
disclosures include the release of information to the following agencies, but are not
limited to: (a) RRB, for administering provisions of the Railroad Retirement Act and
Social Security Act, relating to railroad employment, and for administering provisions of
the Railroad Unemployment Insurance Act; (b) VA, for administering 38 U.S.C. 1312,
and upon request, for determining eligibility for, or amount of, veterans’ benefits or for
verifying other information with respect thereto pursuant to 38 U.S.C. 5106; (c)
Department of Labor for administering provisions of Title IV of the Federal Coal Mine
Health and Safety Act, as amended by the Black Lung Benefits Act; (d) State welfare
departments, for administering sections 205(c)(2)(B)(i)(II) and 402 of the Social Security
Act, which require information about assigned SSNs for Temporary Assistance for Needy
Families (TANF) program purposes, and for determining a beneficiary’s eligibility under
the TANF program; (e) State agencies for administering the Medicaid program; and (f)
State agencies for making determinations of food stamp eligibility under the food stamp
program.

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 SORN 60-0090, entitled Master Beneficiary Record, as

published in the FR on January 11, 2006, at 71 FR 1826. 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
control number. We estimate that it will take about 15 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.