Form SSA-2490-BK Application for Benefits Under a U.S. International Soci

See Revised PRA Attached

See Revised Privacy Act
Statements

The following revised Privacy Act Statement will be inserted into the form
at its next scheduled reprinting:
Privacy Statement
Collection and Use of Personal Information

Sections 205(a), 205(c)(2), and 233 of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide to determine potential
eligibility for receiving benefits under an international agreement on social security or to
determine if we need additional information to support any claims.
Furnishing this information is voluntary. However, failing to provide all or part of the
information may prevent an accurate and timely decision on any claims.
We rarely use the information you supply us for any purpose other than for the reasons explained
above. However, we may use the information for the administration of our programs including
sharing information:
1. 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);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Record Notice entitled, Earnings Records and Self
Employment Income System, (60-0059). Additional information about this and other system of
records notices and our programs is available online at www.socialsecurity.gov or at your local
Social Security office.
We may share the information you provide to other health agencies through 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 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.

The following revised PRA Statement will be inserted 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, gather the facts, and answer the questions. SEND THE
COMPLETED FORM ALONG WITH ANY EVIDENCE TO YOUR LOCAL
SOCIAL SECURITY OFFICE. The office is listed under U. S. Government
agencies in your telephone directory or you may call Social Security at 1-800-7721213 (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.