Form SSA-3441-BK Disability Report--Appeal

See Revised Privacy Act Statement

See Revised Paperwork
Reduction Act

SSA will insert the following revised Privacy Act Statement Statement into
the form at its next scheduled reprinting:
Privacy Act Notice
We are authorized to collect the information on this form under sections 205(a) and (b),
223(d), and 1631(e)(1) of the Social Security Act. We will use the information you
provide on this form to make a decision on your claim or case. Your response to this
request is voluntary. However, failure to provide all or part of the information could
prevent us from making an accurate and timely decision on your claim or case.
We rarely use the information you supply for any purpose other than for determining
your living arrangements. 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 Special Veterans Benefits; (2) to comply with Federal laws
requiring the release of information from Social Security records (e.g., to 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.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.socialsecurity.gov or at any 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 45
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.