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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
Sections 205(b), 205(d), and 1631(c) 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 completing the hearing process.
We will use the information to document your waiver of rights to receive written notice of the
hearing in your case. We may also share your information for the following purposes, called
routine uses:
1. 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
2. To student volunteers and other workers, who technically do not have the status of
Federal employees, when they are performing work for SSA as authorized by law,
and they need access to personally identifiable information in SSA records in order to
perform their assigned Agency functions.
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) 60-0005, entitled Administrative Law Judge Working File on Claimant Cases and 600089, entitled Claims Folders Systems. Additional information and a full listing of all our
SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.

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 2 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.