SSA-9000-F6 Request for Accommodation

Form Approved
OMB No 0960-0777

Social Security Administration

Request for Accommodation
1A. NAME

REQUESTOR INFORMATION

[1 B. DATE OF REQUEST

1C. ADDRESS

1D. SOCIAL SECURITY NUMBER

1E. PHONE NUMBER
(including area code)

ADDITIONAL INFORMATION

2. CONDITION THAT CAUSES YOU TO REQUEST AN
ACCOMMODATION

Form SSA-9000-FS (11-2010)
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3. EXPLANATION

A. Tell us why we cannot communicate with you by sending you notices
in standard print by first-class mail.

B. Tell us why we cannot communicate with you by sending you notices
in standard print by certified mail.

C. Tell us why we cannot communicate with you by sending notices in
standard print by first class mail followed by a telephone call within 5
business days to read you the notice.

D. Tell us why we cannot communicate with you by sending notices in
Braille and in standard print by first-class mail.

Form SSA-9000-FS (11-2010)
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3. EXPLANATION (Continued)

E. Tell us why we cannot communicate with you by sending notices
in a Microsoft Word file on a compact disc (CD) and in standard
print by first-class mail. Most screen readers should be able to
read the Microsoft Word file on the CD. The Word CD will not
work in an audio CD player.

F. Tell us why we cannot communicate with you by sending notices
in large print (18-point font) and in standard print by first-class
mail.

G. Tell us why we cannot communicate with you by sending notices
on audio compact discs (CDs) that contain a voice recording of
the notice and in notices in standard print by first-class mail. The
audio CD should work in most CD players.

Form SSA-9000-FS (11-2010)
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4. Other Accomodation Requested
A. What format do you want?

B. Is there any other way that we can communicate with you?

Form SSA-9000-FS (11-2010)
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Privacy Act Notice for Request for Accommodation

See Revised Privacy Act Statement Attached

The Rehabilitation Act of 1973 (as amended), 29 U.S.C. §§ 701 et seq., and
Section 205(a) of the Social Security Act (as amended), 42 U.S.C. § 405(a),
authorize us to collect this information. The information is needed to verify
your identity and to process your request for a notice accommodation.
Providing this information is voluntary. However, failure to provide all or
part of the requested information may prevent the Social Security
Administration from processing your request.
We rarely use the information you supply for any purpose other than for
verifying identity and processing your notice accommodation request.
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: (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 and
Department of Veteran 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.

Form SSA-9000-FS (11-2010)
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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 and for repayment of payments or delinquent debts under
these programs.
Our notices, additional information regarding this application, and
information regarding our programs and systems, are available on-line
at www.socialsecurity.2ov or at your local Social Security office.
See Revised PRA Statement Attached

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 20
minutes to read the instructions, gather the facts, and answer the
questions. 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.

Form SSA-9000-FS (05-2010)
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SSA will insert the following revised Privacy Act Statement into the form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Section 504 of the Rehabilitation Act of 1973 allows us to collect this information. Furnishing
us this information is voluntary. However, failing to provide all or part of the information may
prevent us from providing you with the accommodation you are requesting.
We will use the information to process your request for reasonable accommodation. We may
also share your information for the following purposes, called routine uses:
1. To contractors and Federal, State, or local agencies, as necessary, to assist Social Security
Administration (SSA) in providing accommodations to members of the public seeking
access to our programs and activities, in compliance with Section 504 of the
Rehabilitation Act of 1973. We will disclose information under this routine use pursuant
only to a written agreement between SSA and that contractor or agency; and
2. To Federal, State, or local agencies (or agents on their behalf) for providing
accommodations to members of the public in compliance with Section 504 of the
Rehabilitation Act of 1973, when that agency is administering cash or non-cash income
maintenance or health maintenance programs (including programs under the Social
Security Act).
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) 60-0378, entitled Requests for Accommodation from Members of the Public.
Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia.bluebook.

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 20 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments relating to our time estimate
above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-0001.