1st Party Internet Social Security Benefits Application (iClaim) - Domestic Applicants

Privacy Act Statement

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Social Security
The Official Website of the U.S. Social Security Administration

Privacy Act Statement
Collection and Use of Information From the Application
If you are the applying for yourself

For The Applicant

See Revised Privacy Act Statement for Applicant Attached

We are authorized to collect the information on this form under sections 202(a),

205(a), and 1872 of the Social Security Act, as amended (42 U.S.C. 402(a), 405
(a), and 1395(ii)). While it is voluntary, except in the circumstances explained
below, we may not pay benefits unless we receive an application. Your response
is mandatory where the refusal to disclose certain information affecting your right
to payment would reflect a fraudulent intent to secure benefits not authorized by
the Social Security Act. We need the information on this form to determine if you
and your dependents are entitled to insurance coverage and/or monthly benefits.
If you do not provide all or part of this information, it could prevent us from
making an accurate and timely decision on your claim or your dependent's claim,
and could result in the loss of some benefits or insurance coverage.
The information you furnish on this form is almost never used for any purpose
other than to determine if you and your dependents are entitled to insurance
coverage and/or monthly benefits. However, there is a possibility that for the
administration of the Social Security programs or for the administration of
programs requiring coordination with the Social Security Administration, we may
disclose information to another person or to another agency as follows:
1. To enable a third party or an agency to assist Social Security in
establishing rights to Social Security benefits and/or coverage;
2. To comply with federal laws requiring the release of information from
Social Security records (e.g., to the General Accountability Office and
Department of Veterans' Affairs); and
3. To facilitate statistical research and audit activities necessary to assure
the integrity and improvement of the Social Security programs (e.g., to
the Bureau of the Census and private concerns under contract to Social
Security).
We may also use the information you provide without your consent in automated
matching programs. These matching programs are computer comparisons of our
records with records kept by other Federal agencies or State or local

http://www.socialsecurity.gov/info/isba/privacyact.htm

7/1/2013

Privacy Act Statement

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government agencies. Information from these matching programs can be used
to establish or verify a person's eligibility for Federally funded or administered
benefit programs and for repayment of payments or delinquent debts under
these programs.
Explanations about these and other reasons why information you provide us
may be used or given out are available in Social Security offices. If you want to
learn more about this, contact any Social Security office.
If you are helping someone

For the Third Party Filer

See Revised Privacy Act Statement for Third Party Filer Attached
The Social Security Administration (SSA) is allowed to collect the information
you provide about yourself as a third party filer on this application under Section
205 of the Social Security Act. We need this information to identify who you are
as the third party filer and to provide it to the claimant on the summary sheet of
the application. Giving us this information is voluntary. However, without it we
may not be able to process the application.
While the information you furnish on this form would almost never be used for
any purpose other than the intended use of this form, such information may be
disclosed by SSA as generally permitted under 5 U.S.C. § 552a(b) of the Privacy
Act of 1974, as amended. This includes using the information as necessary for
administrative purposes or as authorized by routine uses in the applicable
Privacy Act system of records.
Explanations about possible reasons why information you provide us may be
used or given out are available upon request from any Social Security office.

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Last reviewed or modified 10/22/2012

http://www.socialsecurity.gov/info/isba/privacyact.htm

7/1/2013

SSA will insert the following revised Applicant Privacy Act Statement into the iClaim website upon
OMB's approval:
Privacy Act Statement
Collection and Use of Information
Sections 202, 205, and 223 of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide to determine if you or a dependent are
eligible for insurance coverage and/or monthly benefits.
The information you furnish on this form is voluntary. However, failing to provide all or part of
the requested information may prevent us from making an accurate and timely decision
concerning your or a dependent's entitlement to benefit payments.
We rarely use the information you supply for any purpose other than determining benefit
payments for you or a dependent. However, we may use it for the administration and integrity of
our programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, including but not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to Social Security
benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity of Social Security programs. (e.g., to the Bureau of Census and to private
entities under contract with us).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. We use the information from these programs to establish or verify a person's eligibility
for federally funded or administered benefit programs and for repayment of incorrect payments
or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Privacy Act Systems of
Records Notices entitled, Earnings Recording and Self Employment Income System (60-0059)
and Claims Folders Systems (60-0089). Additional information regarding these and other
systems of records notices are available on-line at www.socialsecurity.gov or at your local Social
Security office.

SSA will insert the following revised Third Party Filer Privacy Act Statement into the iClaim
website upon OMB's approval:
Privacy Act Statement
Collection and Use of Information
Sections 205 and 223 of the Social Security Act, as amended, authorize us to collect this
information. We will use the information you provide, as a third party filer on this application,
to identify who you are as the third party filer and to provide it to the claimant on the summary
sheet of the application.
Furnishing us the information is voluntary. However, failing to provide all or part of the
requested information may prevent us from processing the application.
We rarely use the information you supply for any purpose other than identifying you as the third
party filer. However, we may use it for the administration and integrity of our programs. We may
also disclose information to another person or to another agency in accordance with approved
routine uses, including but not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to Social Security
benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity of Social Security programs. (e.g., to the Bureau of Census and to private
entities under contract with us).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. We use the information from these matching programs to establish or verify a person's
eligibility for federally funded or administered benefit programs and for repayment of incorrect
payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Privacy Act Systems of
Records Notices entitled, Earnings Recording and Self Employment Income System (60-0059)
and Claims Folders Systems (60-0089). Additional information regarding these and other
systems of records notices are available on-line at www.socialsecurity.gov or at your local Social
Security office.