Form SSA-96 BK SSA-96 BK Instructions for Completing of Federal Assistance Applic

See Revised Paperwork Reduction Act and Privacy Act
statements below.

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 14 hours
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.

Privacy Act Statement
Collection and Use of Personal Information
Section 1110 of the Privacy Act, as amended, authorizes us to collect this information.
The information you provide will be used to make a determination on your application
for a grant. Without this information we will be unable to consider your request for a
grant.
Additional information regarding this form, and our programs and systems, is available
on-line at www.socialsecurity.gov or at your local Social Security office.