Questionnaire for Children Claiming SSI Benefits - Intranet Version

Privacy Act Statement
Collection and Use of Personal Information
Sections 223(b), 1614, and 1631(e)(1) of the Social Security Act, as amended, allow us to collect
this information, which we will use to determine benefits eligibility. Providing this information
is voluntary, but not providing all or part of the information may delay the determination or
continued eligibility of benefits. As law permits, we may use and share the information you
submit, including with other Federal agencies, contractors, and others, as outlined in the
routine uses within System of Records Notices 60-0089, 60-0103, and 60-0320, available at
www.ssa.gov/privacy. The information you submit may also be used in computer matching
programs for Federal benefits eligibility and to recoup debts under these programs.