Form SSA-754-F4 Statement of Marital Relationship

See revised
Privacy Act
Statement

SSA will insert the following revised PRA Statement into the form as soon
as possible:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget (OMB) control number. We estimate that it will take about
30 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.

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

Section 216(h) of the Social Security Act, as amended, allows 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 any claim filed.
We will use the information to determine your eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
1. To Federal, State or local agencies for administering cash or non-cash income
maintenance or health maintenance programs; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration in the efficient administration of its 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
(SORN) 60-0089, entitled Claims Folders Systems, and 60-0090, entitled Master Beneficiary
Record. Additional information and a full listing of all our SORNs are available on our website
at www.ssa.gov/privacy/sorn.html.

See Revised PRA