Request for Change in Repayment Notice

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 204, 1631(b), and 1879 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 an accurate and timely decision on your overpayment waiver or
change in repayment rate request.
We will use the information to make a determination regarding overpayment recovery and rate of
repayment. We may also share your information for the following purposes, called routine uses:
1. To employers to assist the Social Security Administration (SSA) in the collection of debts
owed by former beneficiaries and representative payees of Social Security payments who
received an overpayment and owe a delinquent debt to the SSA; and
2. To another Federal agency that has asked SSA to effect an administrative offset under
common law or under 31 U.S.C. 3716 to help collect a debt owed the United States.
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) 60-0094, entitled Recovery of Overpayments, Accounting and Reporting/Debt
Management System; 60-0231, entitled Financial Transactions of SSA Accounting and Finance
Offices; and 60-0320, entitled Electronic Disability Claims File. Additional information and a
full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.