Ssa-1709

SSA will insert the following revised PRA Statement into the form as soon as possible:

Privacy Act Statement
Collection and Use of Personal Information

Section 224 of the Social Security Act, as amended, allows us to collect this information. Furnishing us this information is voluntary. However, failing to provide us with all or part of the information could prevent us from making an accurate and timely decision on this claim and could affect the claimant’s benefits.

We will use the information you provide to determine the effect of the claimant’s worker’s compensation or public disability benefit on his or her Social Security disability insurance benefits. We may also share this information for the following purposes, called routine uses:

• To Federal, State, or local agencies (or agents on their behalf) for administering cash or non-cash income maintenance or health maintenance programs;

• To specified business and other community members and Federal, State, and local agencies for verification of eligibility for benefits under section 1631(e) of the Social Security Act; and

• To the Department of the Treasury for collecting Social Security taxes or as otherwise pertinent to tax and benefit payment provisions of the Social Security Act.

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, Claims Folders Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784 and 60-0090, 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, is available on our website at www.ssa.gov/privacy.