Statement About Food or Shelter Provided to Another

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 1612(a)(2)(A) and 1631(e)(1)(B) of the Social Security Act, 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 us from making an accurate and timely decision on a claim for Supplemental Security Income (SSI) or could result in the loss of benefits.

We will use the information to identify bona fide loans of food and shelter and determine an income value, if any, of food and shelter received. We may also share your information for the following purposes, called routine uses:

• To third party contacts, where necessary, to establish or verify information provided by representative payees or payee applicants; and

• 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 (SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784, and 60-0103, entitled SSI 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 our SORNs, is available on our website at www.ssa.gov/privacy.