SSA-5 -Revised PA and PRA Statements

SSA will insert the following revised Privacy Act and PRA Statements into
the form as soon as possible:
Privacy Act Statement

Collection and Use of Personal Information
Sections 202, 205, 223, 226, and 806 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 a timely and accurate decision on your, or
the dependent’s entitlement benefits.
We will use the information to determine your and/or the dependent’s eligibility for Social
Security benefits. We may also share your information for the following purposes, called
routine uses:
•

To contractors and other Federal Agencies, as necessary, for the purpose of assisting us
in the efficient administration of our programs. We will disclose information under this
routine use only in situations in which we may enter into a contractual or similar
agreement to obtain assistance in accomplishing an SSA function relating to this system
of records; and

•

To student volunteers, individuals working under a personal services contract, and other
workers who technically do not have the status of Federal employees, when they are
performing work for the Social Security Administration (SSA), as authorized by law, and
they need access to personally identifiable information in SSA records in order to
perform their assigned Agency functions.

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 (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; 60-0089, entitled Claims Folders
System, as published in the 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; and 60-0321,
entitled Medicare Database File, as published in the FR on July 25, 2006, at 71 FR 42159.
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 15 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 1-800-772-1213 (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.