Form SSA-1026-SCE SSA - Reporting a Change That May Affect Your Extra Help

See below for
revised Privacy Act
Statement.

Privacy Act Statement
Section 1860 D-14 of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide in determining your continuing eligibility
for Medicare prescription drug plan benefits.
The information you furnish on this form is voluntary. However, failure to provide all or part of
the information could prevent an accurate and timely decision on continuing benefit eligibility
and could result in the loss of Extra Help with Medicare prescription drug plan costs.
We rarely use the information you supply for any purpose other than for establishing benefit
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 (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, Medicare Database File, 60-0321. This notice, 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.