Farm Self-Employment Questionnaire

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 205(b)(1), 205(c)(2)(A) and 211(a) 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 the claim
for benefits.
We will use the information to determine your eligibility for 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 the
Social Security Administration in the efficient administration of its programs; and



To student volunteers and other workers, who technically do not have the status of
Federal employees, when they are performing work for 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) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784 and 60-0090, entitled Master Beneficiary Record, as published in
the FR on January 11, 2006, at 71 FR 1826. Additional information, and a full listing of all of
our SORNs, is available on our website at www.ssa.gov/privacy/.

Example of a Standard PA Statement:

Privacy Act Statement
Collection and Use of Personal Information
Section 1148 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 limit your ability to participate in the Work Incentives Planning and Assistance
(WIPA) program.
We will use the information to determine if you qualify for the WIPA program. We may also
share your information for the following purposes, called routine uses:


To State or Employment Networks having an approved business arrangement with SSA
to perform vocational rehabilitation services for SSA; and



To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA
in the efficient administration of its programs 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)
60-0300, entitled Ticket-to-Work Program Manager (PM) Management Information System, as
published in the Federal Register (FR) on July 3, 2002, at 67 FR 44658. Additional information
and a full listing of all our SORNs are available on our website at www.ssa.gov/privacy/.