SSA-9000-F6 Request for Accommodation

Form SSA-9000-F6 (05-2020) UF
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0777

REQUEST FOR ACCOMMODATION
REQUESTOR INFORMATION
1A. Name

1B. Date of Request

1C. Address
1D. Social Security Number

1E. Phone Number
(include area code)

ADDITIONAL INFORMATION
2. Condition that causes you to request an accommodation

Form SSA-9000-F6 (05-2020)
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3. Explanation
A. Tell us why we cannot communicate with you by sending you
notices in standard print by first-class mail.

B. Tell us why we cannot communicate with you by sending you
notices in standard print by certified mail.

C. Tell us why we cannot communicate with you by sending notices
in standard print by first class mail followed by a telephone call
within 5 business days to read you the notice.

D. Tell us why we cannot communicate with you by sending notices
in Braille and in standard print by first-class mail.

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3. Explanation (Continued)
E. Tell us why we cannot communicate with you by sending notices
in a Microsoft Word file on a compact disc (CD) and in standard
print by first-class mail. Most screen readers should be able to
read the Microsoft Word file on the CD. The Word CD will not
work in an audio CD player.

F. Tell us why we cannot communicate with you by sending notices
in large print (18-point font) and in standard print by first-class
mail.

G. Tell us why we cannot communicate with you by sending notices
on audio compact discs (CDs) that contain a voice recording of
the notice and in notices in standard print by first-class mail. The
audio CD should work in most CD players.

Form SSA-9000-F6 (05-2020)
4. Other Accommodation Requested
A. What format do you want?

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B. Is there any other way that we can communicate with you?

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Privacy Act Statement
Collection and Use of Personal Information
Section 504 of the Rehabilitation Act of 1973 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 providing
you with the accommodation you are requesting.
We will use the information to process your request for reasonable
accommodation. We may also share your information for the following
purposes, called routine uses:
• To contractors and Federal, State, or local agencies, as necessary,
to assist Social Security Administration (SSA) in providing
accommodations to members of the public seeking access to our
programs and activities, in compliance with Section 504 of the
Rehabilitation Act of 1973. We will disclose information under this
routine use pursuant only to a written agreement between SSA and
that contractor or agency; and,
• To Federal, State, or local agencies (or agents on their behalf) for
providing accommodations to members of the public in compliance
with Section 504 of the Rehabilitation Act of 1973, when that
agency is administering cash or non-cash income maintenance or
health maintenance programs (including programs under the Social
Security Act).
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.

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A list of additional routine uses is available in our Privacy Act System of
Records Notice (SORN) 60-0378, entitled Requests for Accommodation
from Members of the Public, as published in the Federal Register (FR)
on June 17, 2014, at 79FR 34558. Additional information, and a full
listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy/.
See Revised PRA Statement Attached

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 20 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.