Agreement to Sell Property

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

Section 1613(b) of the Social Security Act, as amended, allows us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent an accurate and timely decision on any claim filed and could result in
the loss of some benefits.
We will use the information to make a determination of eligibility for benefits. We may also
share your information for the following purposes, called routine uses:
1. To State agencies to enable them to assist in the effective and efficient administration of
Supplemental Security Income program; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration in the efficient administration of its program.
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 Notice
(SORN) 60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits.
Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.

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 10 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.