PRA and PA Statments

Privacy Act Statement

Collection and Use of Personal Information

Section 205(a) of the Social Security Act, as amended, [42 U.S.C. 405(a)] authorizes us to collect this information. We will use the information you provide to help us determine the identity of your spouse. The information you furnish on this form is voluntary. However, failure to provide the requested information may prevent us from paying benefits to your spouse.

We rarely use the information you supply for any purpose other than for determining the identity of a spouse. 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 and audit activities necessary to assure the integrity and improvement of Social Security programs (e.g., to the Bureau of the Census and private entities under contract with us).

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. We use the information from these matching programs to establish or verify a person’s eligibility for Federally-funded or administered benefit programs and for repayment of incorrect 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 Claims Folders Systems, 60-0089 and Master Beneficiary Record 60-0090. The notices, additional information regarding this form, and information regarding our systems and programs, are available on-line at www.ssa.gov or at any local Social Security office.

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 5 minutes to read the instructions, gather the facts, and answer the questions.  SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).  You may send comments on our time estimate above to:  SSA, 6401 Security Blvd., Baltimore, MD  21235-6401.  Send only comments  relating to our time estimate to this address, not the completed form.