Certificate of Coverage Request via Internet - Individuals (minus Denmark, Netherlands, Norway, & Sweden)

Privacy Act Statement

Collection and Use of Personal Information

Sections 205(a) and 233(a) - (c) of the Social Security Act, as amended, authorize us to collect this information. We will use the information you provide to make a benefit eligibility determination.

Furnishing us the information is voluntary. However, failing to provide us with all or part of the requested information may prevent us from correctly determining the benefit.

We rarely use the information for any purpose other than for making a benefit determination. However, we may use it for the administration and integrity of our programs. We may also disclose the information to another person or to another 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 our benefits and 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 make determinations for eligibility in similar heath and income maintenance programs at the Federal, State, and local level; and,

4. To facilitate statistical research, audit, and investigatory activities necessary to assure the integrity and improvement of our programs (e.g., to the Bureau of the Census and to 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 programs to establish or verify

a person’s eligibility for federally funded and administered benefit programs and for

repayment of incorrect payments or delinquent debts under these programs.

A complete list of routine uses of this information is available in our Privacy Act Systems

of Records Notice entitled, Earnings Recording and Self-Employment Income System, 60-0059. This notice and additional information regarding our programs and systems are available on-line at www.socialsecurity.gov or at your Social Security office.