SSA-2490-BK (current)

See Revised PRA Attached

See Revised Privacy Act
Statements

The following revised Privacy Act Statement will be inserted into the form
at its next scheduled reprinting:
Privacy Act Statement
Application for Benefits under a U.S. International Social Security Agreement
Sections 205(a), 205(c)(2) and 233 of the Social Security Act, as amended, authorizes us
to collect this information. The information you provide on this form determine you
benefits under an international agreement on social security. You do not have to give us
the information. Your response is voluntary. However, failure to provide us with the
requested information could prevent us from making an accurate and timely decision on
your claim.
We rarely use the information provided 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, the General
Services Administration, the National Archives and Records Administration, and
the Department of Justice);
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, and investigative activities necessary to
ensure the integrity and improvement of Social Security programs.
We may also use this information in computer matching programs. Computer matching
programs compare our records with those of 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 or administered benefit programs and for
repayment of payments or delinquent debts under these programs.
A complete list of routine uses of the information provided is available in our Systems of
Records Notice entitled, Earnings Records and Self Employment Income System, (600059). Additional information about this notice and our programs are available on-line at
www.socialsecurity.gov or at your local Social Security Office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 30
minutes to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM ALONG WITH ANY EVIDENCE TO YOUR LOCAL
SOCIAL SECURITY OFFICE. The office is listed under U. S. Government
agencies in your telephone directory or you may call Social Security at 1-800-7721213 (TTY 1-800-325-0778). You may send comments on our time estimate above to:
SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to
our time estimate to this address, not the completed form.