Application for Mother's of Father's Insurance Benefits / SSA-5-BK

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 202, 205, 223, 226, and 806 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
entitlement or a dependent’s entitlement to Social Security benefit payments.
We will use the information to determine your or a dependent’s eligibility for Social Security
benefits. We may also share your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies (or agents on their behalf) for administering income
maintenance or health maintenance programs (including programs under the Social
Security Act). Such disclosures include, but are not limited to, release of information to:
Railroad Retirement Board for administering provisions of the Railroad Retirement Act
relating to railroad employment; for administering the Railroad Unemployment Insurance
Act and for administering provisions of the Social Security Act relating to railroad
employment; and Department of Veterans Affairs for administering 38 U.S.C. 1312, and
upon request, for determining eligibility for, or amount of, veterans benefits or verifying
other information with respect thereto pursuant to 38 U.S.C. 5106; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs. We
will disclose information under the routine use only in situations in which SSA may enter
into a contractual or similar agreement with a third party to assist in accomplishing an
agency function relating to this system of records.
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) 60-0059, Earnings Recording and Self-Employment Income System, 60-0089, entitled
Claims Folders Systems, 60-0090, entitled Master Beneficiary Record, and 60-0321, entitled
Medicare Database. Additional information and a full listing of all our SORNs are available on
our website at www.ssa.gov/privacy/sorn.html.
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.