Form SSA-5666 Request for Administrative Information

See revised
Paperwork
Reduction Act

See Revised PRA

SSA will insert the following revised Privacy Act Statement into the form at
its next scheduled reprinting
Privacy Act Statement
Request for Administrative Information
Collection and Use of Personal Information
Sections 1614 and 1633 of the Social Security Act, as amended, and 20 CFR 416.924a(a),
authorize us to collect this information. We will use the information you provide to make
a decision on the named claimant’s claim.
The information you furnish on this form is voluntary. However, failure to provide the
requested information could prevent us from making an accurate and timely decision on
the named claimant’s claim.
We rarely use the information you supply for any other purpose than to make a decision
on a claimant’s disability. 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 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.
Explanations about these and other reasons why information you provide us may be used
or given out are available in Systems of Records Notice 60-0089 (Claims Folder
Systems). The Notice, additional information about this form, and any other information
regarding our systems and programs, 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 30 minutes to read the instructions, answer the questions, and collect school
records. If you have questions about how to complete the form, contact the Requesting Office; see page 1,
upper left corner, for the name, address, and phone number of the Requesting Office. If you need the
address or phone number of the Requesting Office, you can get it by calling Social Security at 1-800-7721213 (TTY 1-800-325-0778). SEND THE COMPLETED FORM TO THE REQUESTING OFFICE. You
may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 212356401. Send only comments relating to our time estimate to this address, not the completed form.