Form SSA-3369 Work History Report

See below for
revised Privacy
Act Statement

Privacy Act Statement

Collection and Use of Personal Information

Sections 205(a), 223(d), and 1631(e)(1) of the Social Security Act, as amended, authorize
us to collect this information. We will use the information you provide on this form to
make a decision on the named claimant’s claim.
Completion of this form is voluntary; however, failure to provide all or part of the
requested information could prevent an accurate or timely decision on the named
claimant’s claim.
We rarely use the information you supply for any purpose other than for determining
continuing eligibility. 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.
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 are available in our System of
Records Notices entitled, Claims Folders Systems (60-0089) and the Master Beneficiary
Record (60-0090). These notices, additional information regarding this form, routine uses
of information, and our programs and systems are available on-line at
www.socialsecurity.gov or at your local Social Security office.