Financial Disclosure for Civil Monetary Penalty (CMP) Debt

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(a) and 1129 of the Social Security Act, as amended, and the Inspector General Act of 1978, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on your request.

We will use the information to make a determination regarding the payment of your Civil Monetary Penalty debt. We may also share your information for the following purposes, called routine uses:

• To third party contacts such as private collection agencies and credit reporting agencies under contract with Social Security Administration (SSA) and other agencies, including the Veterans Administration, the Armed Forces, the Department of the Treasury, and State motor vehicle agencies, for the purpose of their assisting SSA in recovering program debt; and

• To third party contacts where the party contacted may have information needed to establish or verify information relevant and necessary to a civil or administrative investigation by the Office of Inspector General (OIG) or in preparation for proceedings pursuant to section 1128A of the Social Security Act, and “Civil Money Penalties.”

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) 60-0094, entitled Recovery of Overpayments, Accounting and Reporting/ Debt Management System, as published in the Federal Register (FR) on August 23, 2005, at 70 FR 49354 and the SSA, OIG’s SORN OIG-002, entitled Civil and Administrative Investigative Files of the Inspector General, SSA/OIG, as published in the FR on April 19, 1995, at 60 FR 19619 (duplicating and incorporating by reference Health and Human Services (HHS) system of records number 09-90-0100, entitled Civil and Administrative Investigative Files of the Inspector General, HHS/OS/OIG, as published in the FR on September 30, 1982, at 47 FR 43190). Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.