Questionnaire for Children Claiming SSI Benefits

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 223(b), 1614, and 1631(e)(1) 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 delay the determination or continued eligibility for benefits.
We will use the information to make a decision on your claim. We may also share your
information for the following purposes, called routine uses:
1. To specified business and other community members and Federal, State, and local
agencies for verification of eligibility for benefits under section 1631(e) of the Act;
2.

To the appropriate State agencies (or other agencies providing services to disabled
children) to identify Title XVI eligibles under the age of 16 for the consideration of
rehabilitation services in accordance with section 1615 of the Act, 42 U.S.C. 1382d; and

3. To third party contacts where necessary to establish or verify information provided by
representative payees or payee applicants.
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) 60-0089, entitled Claims Folders System; 60-0103, entitled Supplemental Security
Income Record and Special Veterans Benefits; and 60-0320, entitled Electronic Disability
(eDIB) Claim File. Additional information and a full listing of all our SORNs are available on
our website at www.socialsecurity.gov/foia/bluebook.