Non-Federal Employee Respondent

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 3371-3375 of title 5 of the U.S. Code allow us to collect this information. Furnishing us
this information is voluntary. However, failing to provide all or part of the information may
result in your ineligibility to participate in the Intergovernmental Personnel Act (IPA) Mobility
Program.
We will use the information you provide to document your IPA assignment. We may also share
the information for the following purposes, called routine uses:
•

To a Federal agency, in response to its request, in connection with the hiring or retention
of an employee, the issuance of a security clearance, the reporting of an investigation of
an employee, the letting of a contract, or the issuance of a license, grant, or other benefit
by the requesting agency, to the extent that the record is relevant and necessary to the
requesting agency’s decisions on the matter; and

•

To a Federal, State or local agency maintaining civil, criminal or other relevant
enforcement records or other pertinent records, such as current licenses, if necessary to
obtain a record relevant to an agency decision concerning the hiring or retention of an
employee, the issuance of a security clearance, the letting of a contract, or the issuance of
a license, grant, or other benefit.

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 the U.S. Office of Personnel Management’s
(OPM) government-wide System of Records Notice (SORN) OPM/GOVT-1, entitled General
Personnel Records, as published in the Federal Register on December 11, 2012, at 77 FR 73694;
and in our Privacy Act SORN 60-0239, entitled Personnel Records in Operating Offices, as
published in the Federal Register on January 11, 2006, at 71 FR 1859. Additional information,
and a full listing of all of 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 30 minutes to read the instructions,
gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM
TO THE EXECUTIVE & SPECIAL SERVICES STAFF AS LISTED ON PAGE 1 OF
THIS DOCUMENT. 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.