Statement of Claimant or Other Person

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 205 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 affect our ability to properly adjudicate claims or resolve entitlement and
eligibility issues.
We may use the information to make a determination on program or non-program related
matters. We may also share the information for the following purposes, called routine uses:


To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA
in the efficient administration of its programs; and,



To student volunteers and other workers, who technically do not have the status of
Federal employees, when performing work for SSA as authorized by law, and they need
access to personally identifiable information in SSA records in order to perform their
assigned Agency functions.

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 System, as published in the Federal Register (FR) on April 1,
2003, at 68 FR 15784, 60-0090, Master Beneficiary Record, as published in the FR on January
11, 2006, at 71 FR 1826, and 60-0103, Supplemental Security Income Record and Special
Veterans Benefits, as published in the FR on January 11, 2006, at 71 FR 1830. Additional
information, and a full listing of all of our SORNs, is available on our website at
https://www.ssa.gov/privacy.