SSA-7162-OCR-SM--Report to U.S. SSA

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 203, 205, and 1631 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 any claim filed.
We will use the information to determine continued eligibility for benefits and to monitor
representative payee performance. We may also share your information for the following
purposes, called routine uses:
•

To Department of State and its agents for administering the Social Security Act in foreign
countries through facilities and services of that agency; and

•

To agencies or entities with responsibility for investigating or addressing possible
financial exploitation of, an immediate health or safety threat to, or other serious risk to
the well-being of the beneficiary, for referral, when these issues are identified during a
representative payee review.

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, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784, and 60-0320, entitled Electronic Disability Claim File, as
published in the FR on December 22, 2003, at 68 FR 71210. Additional information, and a full
listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.