- 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 61 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 on our time estimate above
to: SSA, 6401 Security Blvd, Baltimore, MD 21235-0001. Send only comments relating to
our time estimate to this address, not the completed form.
Privacy Act and Paperwork Reduction Act Statements
Paperwork Reduction Act Statement
PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.
Sections 205(a), 223(d)(5)(A), 1631(d)(1) and 1631(e)(1) of the Social Security Act, as
amended, authorize us to collect this information. We will use the information you provide to
make a determination of eligibility for Social Security benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of
the information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a
determination regarding benefits eligibility. However, we may use the information for the
administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in
our Privacy Act System of Records Notices 60-0089, entitled Claims Folders Systems; and,
60-0320, entitled Electronic Disability (eDIB) Claim File. Additional information about these
and other system of records notices and our programs are available online at www.
socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State or local government
agencies. Information from these matching programs can be used to establish or verify a
person's eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.