Form SSA-157 Data Exchange Request Form

Form SSA-157 (XX-XXXX)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0802

Data Exchange Request Form (DXRF)
Request for Information from SSA
Data Request
1. Name of organization requesting the data
exchange.
2. Indicate what type of organization you are.

Government

Non-Government

Federal

Commercial Entity

State & Local

Educational Institution

Foreign

Other (Please specify)

Tribal
3. In detail, state the business need for the
requested data and explain how your
organization intends to use it. Use box #36 for
additional information or add attachments as
needed.

4. What specific information are you requesting
from SSA? (Social Security number
verification, benefit verification, disability
payments, data elements, etc.).
5. What data elements will you send to support
your request (e.g., SSN, name, date of birth),
if applicable?
6. Is your organization currently receiving this
information by another means (e.g., paper
reports, etc.)?

Yes - Tell us how your organization identifies and collects this
data; be specific.

No
7. Describe the benefit to your organization of
receiving this data.

8. Is there any benefit to SSA?
Yes - Explain.
For foreign requesters - is your organization
willing to enter into a reciprocal arrangement with
SSA to provide the same information we provide
to you?

No

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Form SSA-157 (XX-XXXX)
9. What is the impact to your organization if it
does not receive this data?
10. SSA generally requires reimbursement for the
data and services provided. Are you willing to
incur costs?

Yes
No

11. Provide your legal authority allowing the
collection of this data from SSA. (Legal
authorities may include statutes, regulations,
and/or Executive Orders that explicitly require
or permit your agency to use SSNs in your
program(s) and request them from SSA, or
get other data from SSA as authorized by
law.) If you are a Federal agency, include
information related to applicable Privacy Act
systems of records in which you will maintain
the requested data.
12. List the organization and job functions/titles
within the organization(s) that will have
access to SSA-provided information.

13. Do you plan to share the data with anyone
other than those listed in question 12?

Yes - List the organization that you will be sharing the data with, job
functions/titles, the form (identifiable, aggregate) in which you intend
to disclose information, and the authority for a third party disclosure.

No
14. How frequently do you want to receive
the data?

Daily

Weekly

Monthly

Yearly

Other (Explain)
15. Based on the frequency selected above,
provide an estimate of the number of records
you will submit for processing.
16. How will we exchange the data?

Batch
Both (Explain)

Online

Other (Explain)
17. Understanding that a typical data exchange
takes 12 months or more to fully implement,
when would you like this data exchange to
begin?
18. List any current or previous data exchanges
your organization has with SSA (i.e., by SSA
agreement number or description).

Security
19. If you are a federal agency, does your
organization have documented information
security policies and procedures to safeguard
SSA-provided information from unauthorized
access and improper disclosure?

Yes - Skip to question 21.
No - Skip to question 21.
Not Applicable - Non-Federal Agency

Form SSA-157 (XX-XXXX)
20. If you are not a federal agency, does your
organization have documented information
security policies and procedures to reduce
information technology security risks to an
acceptable level in accordance with the
Federal Information Security Management
Act (FISMA)?
21. Will the information SSA provides be stored or
processed in an external commercial cloud?

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Yes
No
Not Applicable - Federal Agency

Yes

No - Skip to question 23.

Yes

No

a. What is the name of the Cloud Service
Provider (CSP)?
b. Is the CSP FedRAMP authorized?
(www.fedramp.gov)
22. Is the cloud provider contractually required to
enforce security policies and procedures that
will safeguard the information SSA provides
from unauthorized access and improper
disclosure?

Yes

23. Will the information SSA provides be stored
off-shore: i.e., in a foreign country?

Yes

No

No

Only complete questions 24-29 if you are a state agency.
24. If your agency already has an existing
agreement with SSA to receive SSA data, are
there any other programs or purposes for
requesting SSA data that you wish to add to
the current agreement?

Yes
No

25. Name the programs your agency administers
for which you are requesting SSA data.

26. Indicate whether the programs are federallyfunded (either fully or partially) or statefunded. (If the program is not state funded
but locally funded, i.e., at the city or county
level, please specify.)
27. List the benefits or services provided under
these programs.

28. Does your staff take applications or
determine eligibility for TANF, Medicaid, or
SNAP for any of the programs listed in
question 25?
29. How is the requested SSA data relevant to
determining entitlement/eligibility to benefits
or services under the programs your agency
administers?

Yes - Name the program.

No

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Form SSA-157 (XX-XXXX)

Only complete questions 30-35 if your request is for research and statistical purposes only.
30. Indicate if this is a request for a new project
within a current agreement.
31. Indicate the form of data needed to
accomplish the purposes of your study.
Options include tabulations, statistical
outputs, micro data from SSA's program
records for individuals, and SSA data for
individuals that have been linked to other
sources of data.
32. Describe other sources of data to which you
will be linking SSA data (if applicable).
33. Describe any plans to publish or release the
research results including whether any
supporting documentation will be made
available in identifiable form.
34. Include the length of time you need to retain
the data in and the location where the data will
be housed.
35. Include your planned final disposition of the
SSA data to include the date when the data
will be destroyed.
36. Additional comments:

Reminder: We normally release information in the form of tabulations,
statistical outputs or individual data that cannot be associated with an
individual, and only in rare instances do we release micro data.

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Form SSA-157 (XX-XXXX)

Points of Contact
37. Approving authority contact information for
the person signing the agreement for the
agency requesting the data.

Name:
Title:
Address:
Phone #1:
Phone #2:
Email address:

38. Requester contact information for the agency.

Name:
Title:
Address:
Phone #1:
Phone #2:
Email address:

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 30 minutes to
read the instructions, gather the facts, and answer the questions. Send only comments relating to our
time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.