Statement of Household Expenses and Contributions - Paper Form

SSA will insert the following revised Privacy Act and PRA Statements 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)(A)-(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 an accurate and timely decision on benefit
eligibility and benefit payment amount or could result in the loss of benefits of the named
claimant.
We will use the information to verify household income of the named Supplemental Security
Income claimant or recipient to determine eligibility and benefit payment amount. We may also
share your information for the following purposes, called routine uses:
•

To representative payees, when the information pertains to individuals for whom they
serve as representative payees, for the purpose of assisting the Social Security
Administration in administering its representative payment responsibilities under the Act
and assisting the representative payees in performing their duties as payees, including
receiving and accounting for benefits for individuals for whom they serve as payees; and

•

To third party contacts (e.g., employers and private pension plans) in situations where the
party to be contacted has, or is expected to have, information relating to the individual's
capability to manage his/her affairs or his/her eligibility for, or entitlement to, benefits
under the Social Security program when the data are needed to establish the validity of
evidence or to verify the accuracy of information presented by the individual, and it
concerns one or more of the following, his/her eligibility for benefits under the Social
Security program or the amount of his/her benefit payment.

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 Systems, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784, 60-0103, entitled Supplemental Security Income Record and
Special Veterans Benefits, as published in the FR on January 11, 2006, at 71 FR 1830, and 600320, entitled Electronic Disability Claim File, as published in the FR on December 22, 2003, at
68 FR 71210. Additional information, and a full listing of all our SORNs, is available on our
website at www.ssa.gov/privacy.

Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take about 15 minutes to read the instructions, gather
the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security
office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.