Important Information About Your Appeal, Waiver Rights, and Repayment Options - Paper Form

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

Sections 204, 1631(b), and 1879 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 this information may prevent an accurate and timely decision on the request to lower the rate
of benefit withholding, installment payments, an explanation of the overpayment, an appeal or
waiver.
We will use the information you provide to make a determination on waiving overpayment
recovery or changing your repayment rate. We may also share your information for the
following purposes, called routine uses:

• To student volunteers, individuals working under a personal services contract, and other
workers who technically do not have the status of Federal employees, when they are
performing work for us, as authorized by law, and they need access to personally
identifiable information (PII) in our records in order to perform their assigned agency
functions; and

•

To the Bureau of the Census when it performs as a collecting agent or data processor for
research and statistical purposes directly 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 Folder System, as published in the Federal Register (FR) on
October 31, 2019, at 84 FR 58422, SORN 60-0090, entitled Master Beneficiary Record, as
published in the FR on January 11, 2006, at 71 FR 1826, and SORN 60-0094, entitled Recovery
of Overpayments, Accounting and Reporting/Debt Management System, as published in the FR
on August 23, 2005, at 70 FR 49354. 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.