SSA-827 with wet signature(paper version)

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), 223(d), and 1631(d) 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
claim that could result in a denial or loss of benefits.
We will use the information you provide to determine your eligibility or continuing eligibility for
benefits, and your ability to manage any benefits that you currently receive.
We may also share your information for the following purposes, called routine uses:
1. To State audit agencies for auditing State supplementation payments and Medicaid
eligibility considerations;
2. To third party contacts where necessary to establish or verify information provided by
representative payees or payee applicants; and
3. 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 Notices
(SORNs) 60-0089, entitled Claims Folders Systems; 60-0090, entitled Master Beneficiary
Record; 60-0320, entitled Electronic Disability; and 60-0103, entitled Supplemental Security
Income Record and Special Veterans Benefits. Additional information and a full listing of all
our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.