Statement of Self-Employment Income

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

Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a) and 205(c)(2) allows us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on your claim.

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

• To Federal, State, or local agencies (or agents on their behalf) for the purpose of validating Social Security numbers used in administering cash or non-cash income maintenance programs or health maintenance programs (including programs under the Social Security Act); and

• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA) 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 (SORN) 60-0059, entitled Earnings Recording and Self-Employment Income System, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1819, and 60-0089, entitled Claims Folders System, as published in the FR on October 31, 2019, at 84 FR 58422. Additional information, and a full listing of all our SORNs, is available on our website at www.ssa.gov/privacy.