Certificate of Responsibility for Welfare and Care of Child Not In Applicant's Custody

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 202 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 your claim for Social Security Administration (SSA) provided benefits.

.

We will use the information to determine your eligibility for benefits. We may also share your information for the following purposes, called routine uses:

• Information may be disclosed to contractors and other Federal agencies, as necessary, for the purpose of assisting the SSA in the efficient administration of its programs. We contemplate disclosing information under this routine use only in situations in which SSA may enter a contractual or similar agreement with a third party to assist in accomplishing an agency function relating to this system of records; and

• To a congressional office in response to an inquiry from that office made at the request of the subject of a record.

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 Notice (SORN) 60-0089, entitled Claims Folders Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.