Form SSA-4290 Development of Participation in a Vocational Rehabilitat

See revised
Privacy Act
Statement below.

Privacy Act Statement
Collection and Use of Personal Information
Development of Participation in a Vocational Rehabilitation or Similar Program,
Form SSA-4290-F4
Public Law 106-170 and section 234 of the Social Security Act, as amended (42
U.S.C. 434) authorize us to collect this information. The information you provide will
allow you or a beneficiary participating in the Ticket-to-Work and Self-Sufficiency
Program to have more choices in receiving employment services. The information
you provide on this form is voluntary. However, without this information,
employment services, vocational rehabilitation services or other support services
necessary for a participant to achieve a vocational goal may not be available to him or
her.
We rarely use the information you provide on this form for any purpose other than for
the reasons explained above. 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, General
Services Administration, National Archives Records Administration, and the
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 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 is available in our Systems of
Records Notice entitled, Completed Determination Record--Continuing Disability
Determinations, 60-0050; Claims Folder System, 60-0089; Vocational Rehabilitation
Reimbursement Case Processing System, 60-0221; Electronic Disability (eDib) Claim
File, 60-0320. These notices, additional information regarding this form, and
information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at any Social Security office.