Form SSA-640 (11-2018) Page 8 of 9
Privacy Act Statement
Collection and Use of Personal Information
Sections 204 (a) and 1129, of the Social Security Act, as amended, and the Inspector General Act of 1978, as amended, allow 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 your request.
We will use the information to make a determination regarding the payment of your Civil Monetary Penalty debt. We may also
share your information for the following purposes, called routine uses:
• To third party contacts such as private collection agencies and credit reporting agencies under contract with Social Security
Administration (SSA) and other agencies, including the Veterans Administration, the Armed Forces, the Department of the
Treasury, and State motor vehicle agencies, for the purpose of their assisting SSA in recovering program debt; and
• To third party contacts where the party contacted may have information needed to establish or verify information relevant
and necessary to a civil or administrative investigation by the Office of Inspector General (OIG) or in preparation for
proceedings pursuant to section 1128A of the Social Security Act, and "Civil Money Penalties."
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 Notices (SORN) 60-0094, entitled Recovery of
Overpayments, Accounting and Reporting/Debt Management System as published in the Federal Register (FR) on August 23,
2005, at 70 FR 49354 and the SSA, OIG's SORN OIG-002, entitled Civil and Administrative Investigative Files of the Inspector
General, SSA/OIG, as published in the FR on April 19, 1995, at 60 FR 19619 (duplicating and incorporating by reference Health
and Human Resources (HHS) system of records number 09-90-0100, entitled Civil and Administrative Investigative Files of the
Inspector General, HHS/OS/OIG, as published in the FR on September 30, 1982, at 47 FR 43190). Additional information, and a
full listing of all of 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 2 hours 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 21235-6401. Send only comments
relating to our time estimate to this address, not the completed form.