Privacy Act Statement (revised)

SSA will insert the following Privacy Act Statement into the form as soon as possible:

Privacy Act Statement
Collection and Use of Personal Information

Sections 205(b) and (c) of the Social Security Act, as amended, allow us to collect your information, which we will use to determine eligibility for benefits. Providing the information is voluntary, but not providing all or part of the information may prevent us from making an accurate and timely decision on any claim filed. As law permits, we may use and share the information you submit, including with other Federal agencies, contractors, and others, as outlined in the routine uses within System of Records Notices (SORN) 60-0059, 60-0089, 60-0090, 60-0320 available at www.ssa.gov/privacy. The information you submit may also be used in computer matching programs to establish or verify eligibility for Federal benefit programs and to recoup debts under these programs.