Agency/Employer Government Pension Offset Questionnaire

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 202(k)(5) of the Social Security Act, as amended, authorizes 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 and timely decision
on benefit eligibility.
We will use the information you provide to make a determination of eligibility for Social
Security benefits. We may also share your information for the following purposes, called
routine uses:
•

To third party contacts in situations where the party to be contacted has, or is
expected to have, information relating to his/her eligibility for or entitlement to
benefits under the Social Security program when the data are needed to establish
the validity of evidence or to verify the accuracy of information presented by the
individual, and it concerns his/her eligibility for benefits under the Social Security
program; and; and

•

To contractors and other Federal agencies, as necessary, for the purpose of
assisting Social Security Administration (SSA) in the efficient administration of
its programs. We will disclose information under this routine use only in
situations in which SSA may enter into a contractual or similar agreement with a
third party to assist in accomplishing an agency 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
Notices (SORN) 60-0089, entitled, Claims Folders System, as published in the Federal
Register (FR) on April 1, 2003, at 68 FR 15784 and 60-0090, entitled Master Beneficiary
Record, as published in the FR on January 11, 2006, at 71 FR 1826. Additional
information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.