Form SSA-1372-BK Advanced Notice of Termination of Child's Benefits

See Revised Privacy Act and PRA

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

Sections 202(d) and 205(a) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent an accurate and timely decision on your claim.
We will use the information to verify your school attendance and eligibility for student benefits.
We may also share your information for the following purposes, called routine uses:
1. To third party contacts where necessary to establish or verity information provided by
representative payees or payee applicants; and
2. To applicants, claimants, prospective applicants or claimants, other than the data subject,
their authorized representative payees to the extent necessary to pursue Social Security
claims and to representative payees when the information pertains to individuals for
whom they serve as representative payees, for the purpose of assisting SSA in
administering its representative payment responsibilities under the Social Security Act
and assisting the representative payees in performing their duties as payees, including
receiving and accounting for benefits for individuals for whom they serve as payees.
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) 60-0089, entitled Claims Folders System. Additional information and a full listing of
all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 3
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 21235-6401.

See Revised
Privacy Act
Statement and
PRA

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

Sections 202(d) and 205(a) of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent an accurate and timely decision on your claim.
We will use the information to verify your school attendance and eligibility for student benefits.
We may also share your information for the following purposes, called routine uses:
1. To third party contacts where necessary to establish or verity information provided by
representative payees or payee applicants; and
2. To applicants, claimants, prospective applicants or claimants, other than the data subject,
their authorized representative payees to the extent necessary to pursue Social Security
claims and to representative payees when the information pertains to individuals for
whom they serve as representative payees, for the purpose of assisting SSA in
administering its representative payment responsibilities under the Social Security Act
and assisting the representative payees in performing their duties as payees, including
receiving and accounting for benefits for individuals for whom they serve as payees.
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) 60-0089, entitled Claims Folders System. Additional information and a full listing of
all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 8
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 21235-6401.