Government Pension Questionnaire

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
Section 202(k)(5) 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 your claim and could affect your
Social Security benefit.
We will use the information to determine the effect of your pension on your Social Security
benefit. We may also share the information for the following purposes, called routine uses:
1. To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA
in the efficient administration of its programs; and,
2. To student volunteers, individuals working under a personal services contract, and other
workers who technically do not have the status of Federal employees, when they are
performing work for SSA, as authorized by law, and they need access to personally
identifiable information in SSA records in order to perform their assigned Agency
functions.
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 and 60-0090, entitled Master Beneficiary
Record. Additional information and a full listing of all our SORNs are available on our website
at www.socialsecurity.gov/foia/bluebook.

3/13/2017 9:20 AM