Non-Attorney Representative Demonstration Project --Application

Please see below
for revised Privacy
Act Statement.

Replace text with
"6401 Security
Blvd., Baltimore,
MD 21235-6401."

Reporting Changes That Affect Your Social Security Payment – Form SSA-1425
Privacy Act Statement
Collection and Use of Personal Information
Sections 202, 203, and 205 of the Social Security Act, as amended (42 U.S.C. 402,
403, and 405) authorizes us to collect this information. We will us the information
you provide to assist us in determining your continuing eligibility to benefits or your
benefit amount. The information you provide on this form is voluntary. However,
failure to provide all or part of the requested information could prevent us from
making an accurate and timely decision on your claim or could result in the loss of
benefits.
We rarely use the information you provide on this form for any purpose other than for
the reasons explained above. However, we may use it for the administration and
integrity of Social Security programs. We may also disclose information to another
person or to another agency in accordance with approved routine uses, which include
but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records(e.g., to the Government Accountability Office, General
Services Administration, National Archives Records Administration, and the
Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by other Federal, State, or
local government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally-funded and administered benefit
programs for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of
Records Notice entitled, Claims Folder System, 60-0089. This notice, additional
information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social
Security office.