Claimant Statement About Loan of Food or Shelter

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 1612(a)(2)(A) and 1631(e)(1)(B) 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 a claim for Supplemental Security Income (SSI).

We will use the information to obtain statements about food or shelter provided to SSI claimants or recipients and whether they are bona fide loans or income for SSI purposes.

• To third party contacts, where necessary, to establish or verify information provided by

representative payees or representative payee applicants; and

• To State agencies to enable them to assist in the effective and efficient administration

of the Supplemental Security Income program.

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) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422, and 60-0103, entitled Supplement Security Income Record and Special Veterans Benefits, as published in the FR on January 11, 2006, at 71 FR 1830. Additional information, and a full listing of all our SORNs, is available on our website at www.ssa.gov/privacy.