Discrimination Complaint Form

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

Section 702(a) of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide the information may
prevent us from processing your complaint.
We will use the information you provide to process your complaint. We may also share your
information for the following purposes, called routine uses:
•

To a Federal, State, or local agency for law enforcement purposes concerning a violation
of law pertaining to the records in this system; and

•

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 the Social Security Administration (SSA), as authorized by law, and
they need access to personally identifiable information in SSA records in order to
perform their assigned agency functions.

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) 60-0275, entitled Civil Rights Complaints Filed by Members of the Public, as published
in the Federal Register (FR) on January 11, 2006, at 71 FR 1874. 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 60 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.