Employment Relationship Questionnaire

SSA will insert the following revised PA and PRA Statements into the form as soon as
possible:
Privacy Act Statement
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, allows 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 decision on the worker’s claim.
We will use the information to define a worker’s employment status and ensure accuracy of
earnings records to determine eligibility for benefits. We may also share your information for the
following purposes, called routine uses:
•

To employers, current or former, for correcting or reconstructing earnings records and for
Social Security tax purposes; and

•

To third party contacts (including private collection under contract with us), for the
purpose of their assisting us in recovering overpayments.

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) 60-0089, entitled Claims Folders System, as published in the Federal Registrar (FR) on
October 31, 2019, at 84 FR 58422; 60-0090, entitled Master Beneficiary Record, as published in
the FR on January 11, 2006, at 71 FR 1826; and 60-0330, entitled eWork, as published in the FR
on September 15, 2003, at 68 FR 54037. 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 25 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.