Certificate of Responsibility for Welfare and Care of Child Not In Applicant's Custody

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 202 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 an accurate and timely decision on your claim.
We will use the information to determine whether you meet the statutory “child-in-care”
requirement 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 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 claimants, prospective claimants (other than the data subject), and their authorized
representatives or representative payees, to the extent necessary to pursue Social Security
claims; to representative payees, when the information pertains to individuals for whom
they serve as representative payees, for the purpose of assisting us in administering
representative payment responsibilities under the Social Security Act; and to
representative payees, for the purpose of assisting them in performing their duties as
payees, including receiving and accounting for benefits for individuals for whom they
serve as payees.

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) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
October 31, 2019, at 84 FR 58422. Additional information, and a full listing of all 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 5 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.