SSA-827 with wet signature(paper version) or EDCS Screens with verbal attestation (Intranet version)

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 223(d), 1614(a), and 1631(d) 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 your claim, and could result in a denial or loss of benefits.
We will use the information you provide to determine your eligibility or continuing eligibility of
benefits, and your ability to manage any benefits that you currently receive. We may also share
the information for the following purposes, called routine uses:
•

To State audit agencies for the purpose of: (a) auditing State supplementation
payments and Medicaid eligibility considerations; and (b) expenditures of Federal
funds by the State in support of the Disability Determination Services; and

•

To third party contacts, where necessary, to establish or verify information provided
by representative payees or representative payee applicants.

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 System, as published in the Federal Register (FR) on
October 31, 2019, at 84 FR 58422; 60-0090, entitled Master Beneficiary Record, as published in
the FR on January 11, 2006, at 71 FR 1826; 60-0103, entitled Supplemental Security Income 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 June 4, 2020, at
85 FR 34477. Additional information, and a full listing of all of our SORNs, is available on our
website at www.ssa.gov/privacy.

Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not
need to answer these questions unless we display a valid Office of Management and Budget
control number. We estimate that it will take about 10 minutes to read the instructions, gather
the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security
office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800772-1213 (TTY 1-800-325-0778). You may send comments regarding this burden estimate or
any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate
or other aspects of this collection to this address, not the completed form.