SSA-5665-BK (Electronic)

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 202, 223 and 1631(e) 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 the named
claimant’s eligibility for 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 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; and
2. To Federal, State, or local agencies for administering cash or non-cash income
maintenance or health maintenance programs.
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 Systems. Additional information and a full listing of
all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.