Form SSA-3369 Work History Report

See below for
revised Privacy
Act Statement

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631(e)(1) of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide to make a determination of
eligibility for Social Security benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination
regarding benefits eligibility. However, we may use the information for the administration of
our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notices 60-0089, entitled, Claims Folders
Systems; and, 60-0090, entitled, Master Beneficiary Record. Additional information about these
and other system of records notices and our programs are available online at
www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.