Revised PA & PRA Statements

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 204(a) and 1129 of the Social Security Act, as amended, and the Inspector General Act
of 1978, 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 your request.
We will use the information to make a determination regarding the payment of your Civil
Monetary Penalty debt (CMP). We may also share your information for the following purposes,
called routine uses:
•

To third party contacts such as private collection agencies and credit reporting agencies
under contract with Social Security Administration (SSA) and other agencies, including
the Veterans Administration, the Armed Forces, the Department of the Treasury, and
State motor vehicle agencies, for the purpose of their assisting SSA in recovering
program debt; and

•

To third party contacts where the party contacted may have information needed to
establish or verify information relevant and necessary to a civil or administrative
investigation by the OIG or in preparation for proceedings pursuant to section 1128A of
the Social Security Act, and “Civil Money Penalties.”

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) 60-0094, entitled Recovery of Overpayments, Accounting and Reporting /Debt
Management System, as published in the Federal Register (FR) on August 23, 2005, at 70 FR
49354 and the SSA, OIG’s SORN OIG-002, entitled Civil and Administrative Investigative Files
of the Inspector General, SSA/OIG, as published in the FR on April 19, 1995, at 60 FR 19619.
Additional information and a full listing of all 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 120 minutes to read the instructions, gather
the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security
office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800772-1213 (TTY 1-800-325-0778). You may send comments regarding this burden estimate or
any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate
or other aspects of this collection to this address, not the completed form.