Application for Lump-Sum Death Payment - Paper

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, 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 determination on any claim
filed and could result in a loss of a Social Security Administration (SSA) provided benefit.
We will use the information to authorize our one-time disbursement of the lump-sum death
payment to a widow, widower, or children as defined in Section 202. 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.