Paper Form SSA-16 (Application for Disability Insurance Benefits )

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, 205, and 223 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 us from making an accurate and timely decision concerning your or a dependent’s eligibility to benefit payments.

We will use the information you provide to help us determine your or a dependent’s eligibility for benefit payments. We may also share the information for the following purposes, called routine uses:

1. To State audit agencies for auditing State supplementation payments and Medicaid eligibility considerations.

2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration in the efficient administration of its programs.

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 and 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.

1/14/2021 3:05 AM