Form SA-2574 Information About Joint Checking/Savings Accounts

See Revised
Privacy Act and
Paperwork
Reduction Act
Statements below.

Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e) of the Social Security Act (42 U.S.C. 1383(e)), as amended, authorize us
to collect this information. The information you provide will be used to help determine
eligibility for Supplemental Security Income (SSI) payments.
The information you furnish on this form is voluntary. However, failure to provide the
requested information could prevent you or the person who is applying for or receiving
SSI payments from an accurate and timely decision, and could result in the loss of some
benefits.
We rarely use the information you supply for any purpose other than for making a
determination relating to approval for SSI payments. 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 the following:
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 Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity and improvement of Social Security programs (e.g., to the
Bureau of the Census and private concerns under contract to Social Security).
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 or 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 our Systems of Records
Notices entitled, Master Beneficiary Record, 60-0090 and Supplemental Security Income
Record, 60-0090. These notices, additional information regarding this form, and
information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security office.

SSA will insert the following revised PRA Statement 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 7
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.