SSA-7162-OCR-SM--Report to U.S. SSA

SSA will insert the following revised Privacy Act Statement into the form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 203 and 205 of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may affect the decision on your claim.
We will use the information to make a decision regarding continuing entitlement to benefits. We
may also share your information for the following purposes, called routine uses:
1. To third party contacts in situations where the party to be contacted has, or is expected to
have, information relating to an individual’s capability to manage his/her affairs or
his/her eligibility for or entitlement to benefits under the Social Security program when
the individual is unable to provide the information being sought;
2. To third party contacts where necessary to establish or verify information provided by
representative payees or payee applicants; and
3. To the Department of State and its agents for administering the Act in foreign countries
through facilities and services of that agency.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORNs) 60-0089, entitled Claims Folders Systems. Additional information and a full listing of
all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.