Request for Social Security Statement--paper version

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 205 and 1143 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 the issuance of a Social Security statement.
We will use the information to accurately identify your Social Security earnings record, extract
the recorded earnings history, and to produce the requested statement. We may also share your
information for the following purposes, called routine uses:
1. To Federal, State, or local agencies (or agents on their behalf) for the purpose of
validating Social Security numbers used in administering cash or non-cash income
maintenance programs or health maintenance programs; and
2. To employers or former employers, including State Social Security administrators, for
correcting and reconstructing State employee earnings records and for Social Security
purposes.
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) 60-0059, entitled Earnings Recording and Self-Employment Income System, as
published in the Federal Register (FR) on January 11, 2006, at 71 FR 1819; 60-0090, entitled
Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826; and 600224, entitled SSA-Initiated Personal Earnings and Benefit Estimate Statement Address System,
as published in the FR on October 27, 1994, at 59 FR 54004. Additional information, and a full
listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.