General Request for Social Security Records--eFOIA

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General Request for Social Security Records

Form OPD Internet Request
Form Approved: OMB No. 0960-0716
Expiration Date: 03/31/2012

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Do not use this form to request a photocopy or a computer extract of a Social Security Number application. Please use Form SSA-711.
Do not use this form to request birth or death certificates. The Social Security Administration does not typically maintain these types of documents.
Do not use this form to request missing person information, letter forwarding or earnings information. Please send these requests to:

Social Security Administration
OEO FOIA Workgroup
300 N. Greene Street
P.O. Box 33022
Baltimore, Maryland 21190-3022

* Indicates required information

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Requester's Information

Name

*First	Middle	*Last

Address

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Street Address 2

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PAPERWORK/PRIVACY ACT STATEMENT

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PAPERWORK/PRIVACY ACT STATEMENT

PAPERWORK REDUCTION ACT STATEMENT: This information collection meets the clearance requirements of 44 U.S.C. §3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take you about 3 minutes to read the instructions, gather the necessary facts, and answer the question. You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401

PRIVACY ACT STATEMENT: Applicable regulations at 20 CFR § 402.130 and 5 U.S.C. § 552 authorize us to collect the information requested on this form. We will use the information you provide to respond to your request for information or records maintained by the Social Security Administration (SSA).

The information you furnish on this form is voluntary. However, failure to provide the requested information will prevent us from responding to your request.

We rarely use the information you supply for any purpose other than the one stated above. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or agency in accordance with approved routine uses, including but not limited to the following:

1.To enable a third party or an agency to assist us 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 and Department of Veterans Affairs);

3.To the Department of Justice (DOJ) to defend SSA in FOIA litigation involving a record we maintain in this system of records;

4.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and

5.To facilitate audit or investigative activities necessary to assure the integrity of Social Security programs.

A complete list of routine uses for the information you gave us is available in System of Records Notice Electronic Freedom of Information Act (eFOIA) System (60-0340). The Notice, additional information regarding this form, and information regarding our systems and programs, are available on-line at www.socialsecurity.gov or at your local Social Security office.The Social Security Administration (SSA) has the authority to collect the information requested on this form under 5 U.S.C. § 552 and the applicable regulations at 20 CFR § 402.130. The information you provide will be used to respond to your request for information or records maintained by SSA. You do not have to give us this information. However, without the information we will be unable to respond to your request.