Application for Benefits Under a U.S. International Social Security Agreement (Paper)

SSA will insert the following revised PRA Statement into the form as soon as possible:

Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 205(c)(2), and 233 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 your claim.

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

1. To the Social Security Agency of a foreign country, to carry out the purpose of an international Social Security agreement entered into between the United States and the other country, pursuant to section 233 of the Social Security Act.

2. To any source that has, or is expected to have, information that the Social Security Administration needs in order to establish or verify a person’s eligibility for a certificate of coverage under a Social Security agreement authorized by section 233 of the Social Security Act.

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) 60-0059, entitled Earnings Records and Self Employment Income System, and 60-0090, entitled Master Beneficiary Record. Additional information and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.