Form SSA-L9784 Retirement, Survivors and Disability Insurance: Earnings

See Revised Privacy Act Attached

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
reprinting:
Privacy Act Statement
Retirement, Survivors, and Disability Insurance
Sections 203(h)(3), (4), and 205(a) of the Social Security Act, as amended, authorize us to
collect the information requested on this form. We will use the information to ensure that we are
paying you correctly. The information you provide is voluntary. However, failure to provide us
with the requested information could prevent us from making an accurate and timely decision on
your benefit amount.
We rarely use the information provided on this form for any purpose other than for the
reasons stated above. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose the information provided on this form in accordance
with approved routine uses of the Privacy Act, 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 our records (e.g.,
to the Government Accountability Office, General Services Administration, National
Archives and 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 Systems of Records Notices
entitled, Earnings Recording and Self-Employment Income Record, 60-0059, Claims Folder
System, 60-0089, and Master Beneficiary 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.