Current SSA-7161-INST

Form SSA-7161-INST (04-2011) Destroy Prior Editions

PRIVACY ACT STATEMENT- Collection and Use of
Personal Information--The United States Code of Federal
regulations (42 U.S.C. § 403(c), 403(g), 405(a) and 405(j))
authorize us to collect the information on this form. The
information you provide will be used to determine if we can
continue to pay Social Security benefits on this claim.
Your response is voluntary. However, failure to provide
the requested information may prevent us from making an
accurate and timely decision, or could result in the loss of
benefits.
We rarely use the information provided on this form for any
purpose other than for determining the continued entitlement to benefit payments. However, in accordance with 5
U.S.C. § 552a(b) of the Privacy Act, we may disclose the
information provided on this form (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
make determinations for eligibility in similar health and
income maintenance programs at the Federal, State, and
local level; (3) to comply with Federal laws requiring the
disclosure of the information from our records; and (4) to
facilitate statistical research, audit or investigative activities necessary to assure the integrity of SSA programs.
We may also use the information you provide when we
match records by computer. Computer matching programs
compare our records with those of 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.
A complete list of routine uses for this information is
contained in our System of Records Notice 60-0089
(Claims Folders System). Additional information regarding this form and our other system of records notices and
Social Security programs are available from our Internet
website at www.socialsecurity.gov or at
any U.S.
Embassy, consulate, VARO or Social Security office.

Form SSA-7161-INST (04-2011) Destroy Prior Editions