Ssa-1003

SSA will insert the following revised Privacy Act Staetment into the form as soon as possible:

Privacy Act Statement
Collection and Use of Personal Information

Sections 205 and 209(a)(7) 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 you provide to give the employee credit for the correct amount of wages earned. We may also share your information for the following purposes, called routine uses:

• To a contractor for the purpose of collating, evaluating, analyzing, aggregating or otherwise refining records when the Social Security Administration contracts with a private firm. (The contractor shall be required to maintain Privacy Act safeguards with respect to such records.) ; and

• 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.

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) 60-0059, entitled Earnings Recording and Self-Employment Income System, as published in the Federal Register (FR) on January 11, 2006, at 71 FR 1819. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.