Form SSA-41884 Self-Employment/Corporate Officer Questionnaire

Please see below for revised Paperwork Reduction Act and Privacy Act Statements.

Privacy Act Statement
Section 203, of the Social Security Act, as amended, authorizes us to collect this
information. The information is needed to make a determination regarding the correct
amount of benefits due to you. The information you furnish on this form is voluntary.
However, failure to provide all or part of the information could prevent an accurate and
timely decision on your benefit application.
We rarely use the information you supply for any purpose other than for making a
determination on a claim. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not
limited to: (1) to enable a third party or an agency to assist Social Security in
establishing rights to Social Security benefits and/or coverage; (2) to comply with Federal
laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veteran Affairs); (3) to make
determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; (4) to state audit agencies for auditing State
supplementation payments and Medicaid eligibility; and (5) to facilitate statistical
research, audit or investigative activities necessary to assure the integrity of Social
Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local
government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally funded and administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Record
Notice 60-0089. The notice, additional information regarding this form, and information
regarding our programs and systems, are available on-line at www.ssa.gov or at your
local Social Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 20
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.