Supplemental Security Income Claim Information 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

Section 1611(e)(2) 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 for
Supplemental Security Income (SSI).
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 State agencies to enable them to assist in the effective and efficient administration of
the SSI program; and
2. 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 or her affairs or his
or her eligibility for, or entitlement to, benefits under the Social Security program.
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 60-0103, entitled SSI Record and
Special Veterans Benefits. Additional information and a full listing of all our SORNs are
available on our website at www.ssa.gov/privacy/sorn.html.