Function Report - Child (Birth to 1st Birthday, Age 1 to 3rd Birthday, Age 3 to 6th Birthday, Age 6 to 12th Birthday, Age 12 to 18th Birthday), 20 CFR 416.912 and 416.924a(a)(2)

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 1614(a)(3) and 1631(e) 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 any claim filed.
We will use the information to make a determination of eligibility for Supplemental Security
Income benefits. We may also share your information for the following purposes, called routine
uses:
1. To Federal, State, or local agencies for administering cash or non-cash income
maintenance or health maintenance programs;
2. To appropriate State agencies, or other agencies providing services to disabled children,
to identify Title XVI eligible under the age of 16 for the consideration of rehabilitation
services; and
3. To specified business and other community members and Federal, State, and local
agencies for verification of eligibility for benefits.
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
(SORNs) 60-0089, entitled Claims Folders Systems, as published in the Federal Register (FR),
on April 1, 2003, at 68 FR 15784; 60-0103, entitled Supplemental Security Income Record and
Special Veterans Benefits, as published in the FR on January 11, 2006 at 71 FR 1830; and 600320, entitled Electronic Disability (eDIB) Claim File, as published in the FR on December 22,
2003 at 68 FR 71210. Additional information, and a full listing of all of our SORNs, are
available on our website at www.ssa.gov/privacy/.