Revised PA & PRA Statements

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

Section 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 an accurate and timely decision on any claim filed and may
result in the loss of benefits.
We will use the information you provide to authorize a one-time lump-sum death
payment. 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 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 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 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 1-800-772-1213 (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.