Discrimination Complaint Form

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
Sections 205(a), 223(a) and (d), and 1631 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 any claim filed or could result in the loss of benefits.
We will use the information you provide to determine eligibility for disability 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
Social Security Administration (SSA) in the efficient administration of its programs; and

•

To student volunteers and other workers, who technically do not have the status of
Federal employees, when they are performing work for SSA as authorized by law, and
they access to personally identifiable information in SSA records to perform their
assigned Agency functions.

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 System, as published in the Federal Register (FR) on
April 01, 2003, at 68 FR 15784 and 60-0103, entitled Supplemental Security Income Record and
Special Veterans Benefits, as published in the FR on January 01, 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.

8/2/2019 9:37 AM