State, Local and Tribal Government

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
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 you provide to determine eligibility for benefits. We may also share
the information for the following purposes, called routine uses:


To third party contacts where necessary to establish or verify information provided by
representative payees or payee applicants; and



To employers or former employers for correcting or reconstructing earnings records
and for Social Security tax purposes only.

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) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784. Additional information, and a full listing of all our SORNs, is
available on our website at www.ssa.gov/privacy/.