SSA will insert the following Privacy Act Statement into the form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 808 and 810 of the Social Security Act, as amended, allow us to collect your information, which we will use to determine continuing entitlement and the correct payment amounts. Providing the information is voluntary, but not providing all or part of the information could result in improper payments, overpayments, and the loss of payments. 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 60-0273, 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.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Sasha Nsafoah |
| File Modified | 0000-00-00 |
| File Created | 2026-01-03 |