SSA-634 - Request for Change in Repayment Notice

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 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 us from negotiating a repayment agreement and an accurate and
timely determination on your request for a change in your overpayment recovery rate.
We will use the information you provide to determine if we can approve your request for a
change in your overpayment recovery rate. We may also share the information for the following
purposes, called routine uses:
•

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; and

•

To contractors and other Federal agencies, as necessary, for the purpose of assisting us in
the efficient administration of its programs. We will disclose information under this
routine use only in situations in which we may enter into a contractual or similar
agreement to obtain assistance in accomplishing an SSA function relating to this system
of records.

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 (ROAR/DMS), as published in the Federal Register (FR) on August 23,
2005, at 70 FR 49354; 60-0231, entitled Social Security Online Accounting and Reporting
System, as published in the FR on January 14, 2020 at 85 FR 2224; and 60-0320, entitled
Electronic Disability (eDIB) Claim File, as published in the FR on June 4, 2020, at 85 FR 34477.
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 45 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.