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 (OMB) control number. We estimate that it will take about 3 minutes to read the instructions, gather the facts, and answer the questions. Send only 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.
Privacy Act
Statement
Collection and Use of Personal Information
Section 1619(b) of the Social Security Act allows us to collect this information, which we will use to determine benefits eligibility. Providing this information is voluntary, but not providing the information may prevent us from assisting you with the request. As law permits, we may disclose your information per routine uses in System of Records Notice 60-0089, available at www.ssa.gov/privacy. Your information may also be used in computer matching programs to establish or verify eligibility for Federal benefit programs and to recoup debts under these programs.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | KEH |
| File Modified | 0000-00-00 |
| File Created | 2024-07-24 |