Claim for Amounts Due in the Case of a Deceased Beneficiary

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 204(d) and 1870(g) 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 proper payment of an underpayment or Medicare premium refund due a deceased beneficiary.

We will use the information you provide to determine your eligibility for an underpayment or Medicare premium refund due a deceased beneficiary. We may also share your information for the following purposes, called routine uses:

• To the Department of the Treasury for collecting Social Security taxes or as otherwise pertinent to tax and benefit payment provisions of the Act (including SSN verification services) or investigating alleged theft, forgery, or unlawful negotiation of Social Security checks; and

• 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 System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15785, and 60-0090, entitled Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826. Additional information and a full listing of all our SORNs are available on our website at www.ssa.gov/privacy.

1/21/2021 5:19 AM