Ha-4633

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 205(a), 702, 1631(e) and 1869(b)(1)(C) 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 prevent us from making an accurate and timely
decision on your eligibility for disability benefits.
We will use the information to determine your eligibility for receiving disability 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 the 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 information being sought. An individual is considered
to be unable to provide certain types of information when: he/she is incapable or of
questionable mental capability; he/she cannot read or write; he/she cannot afford the cost
of obtaining the information; he/she has a hearing impairment, and is contacting SSA by
telephone through a telecommunications relay system operator; a language barrier exists;
or the custodian of the information will not, as a matter of policy, provide it to the
individual; or the data are needed to establish the validity of evidence or to verify the
accuracy of information presented by the individual; and it concerns one or more of the
following: his/her eligibility for benefits under the Social Security program; the amount
of his/her benefit payment; or any case in which the evidence is being reviewed as a
result of suspected abuse or fraud, concern for program integrity, or for quality appraisal,
or evaluation and measurement activities.
2. 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.
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
(SORN) 60-0089, entitled Claims Folders Systems; and 60-0320, entitled Electronic Disability
Claim File. Additional information and a full listing of all our SORNs are available on our
website at www.socialsecurity.gov/foia/bluebook.