Ssa-2855

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 1631(e) 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 your eligibility for
Supplemental Security Income (SSI) benefits.
We will use the information you provide to determine your eligibility for SSI benefits. We may
also share your information for the following purposes, called routine uses:
1. To State agencies to enable those agencies which have elected to administer their
supplementation programs to monitor changes in applicant or recipient income, special
needs, and circumstances ; and
2. To State agencies to enable them to assist in the effective and efficient administration of
the SSI 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
(SORNs) 60-0089, entitled Claims Folder 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 https://www.ssa.gov/privacy/sorn.html.

12/18/2017 2:13 PM