Statement of Living Arrangements, In-Kind Support and Maintenance

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled reprinting:

Privacy Act Statement
Collection and Use of Personal Information

Section 1631(e) of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may cause an incorrect determination of your Supplemental Security Income (SSI) eligibility and payments.

We will use the information determine the amount of income you have received, including in-kind support and maintenance in the form of food and shelter provided by another person. We may also share your information for the following purposes, called routine uses:

1. To a Social Security beneficiary/claimant when a claim is filed by another individual on the same record which is adverse to the beneficiary, but only information concerning the facts relevant to the interests of each party in a claim; e.g.: (a) An award of benefits to a new claimant precludes an award to a prior claimant; or (b) An award of benefits to a new claimant will reduce the benefit payments to the individual(s) on the roll; and

2. To the following Federal and State agencies to prepare information for verification of benefit eligibility under section 1631(e) of the Social Security Act: Bureau of Indian Affairs; Office of Personnel Management; Department of Agriculture; Department of Labor; U.S. Citizenship and Immigration Services; Internal Revenue Service; Railroad Retirement Board; State Pension Funds; State Welfare Offices; State Worker's Compensation; Department of Defense; United States Coast Guard; and Department of Veterans Affairs.

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 Notices (SORN) 60-0090, entitled Master Beneficiary Record; and 60-0103, entitled Supplemental Security Income Record. Additional information and a full listing of all our SORNs are available on our website at https://www.ssa.gov/privacy/sorn.html.