Waiver of Supplemental Security Income Payment Continuation

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 1631 of the Social Security Act, as amended, allows 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 any claim filed.
We will use the information to further document your claim and make a determination regarding
your Social Security benefits. We may also share your information for the following purposes,
called routine uses:
•

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 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 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 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 individual, and it concerns
his/her eligibility for benefits under the Social Security 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 Notice
(SORN) 60-0103, entitled Supplemental Security Income, as published in the Federal Register
(FR) on January 11, 2006, at 71 FR 1830. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy/.