f) 20 CFR 411.575 - SSA-1391; SSA-1389; SSA-1399; SSA-1398

SSA will insert the following revised Privacy Act and PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information
Section 1148 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 prevent us from assigning your ticket to your selected service provider.
We will use the information to monitor your progress in the Ticket to Work and Self Sufficiency
Program. We may also share your information for the following purposes, called routine uses:


Disclosure to contractors and other Federal agencies, as necessary, for the purpose of
assisting the Social Security Administration (SSA) in the efficient administration of its
programs; and



Information may be disclosed to state or employment networks having an approved
business arrangement with SSA to perform vocational rehabilitation services for SSA
disability beneficiaries and recipients.

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) 60-0295, entitled Ticket-to-Work and Self-Sufficiency Program Payment Database, as
published in the Federal Register (FR) on April 4, 2001, at 66 FR 17985 and 60-0300, entitled
Ticket-to-Work Program Manager Management Information System, as published in the FR on
June 15, 2001, at 66 FR 32656. Additional information, and a full listing of all of our SORNs, is
available on our website at www.ssa.gov/privacy.

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 10 minutes to read the instructions, gather the facts, and answer the questions.
SEND THE COMPLETED FORM TO: OPERATIONS SUPPORT MANAGER (OSM)
TICKET TO WORK, Attn: Ticket Assignment, PO BOX 1433, ALEXANDRIA, VA
22313 OR FAX TO 703-893-4149. 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.