Sections 205(a), 702, 1631(e)(1)(A) and (B), and 1869(b)(1) and (c), as amended, authorizes us to
collect the information requested on this form. The information you provide will be used to make a
decision on this claim. Your response is voluntary. However, failure to provide the requested
information may prevent an accurate and timely decision on any claim filed, or could result in the
loss of benefits.
We rarely use the information provided on this form for any purpose other than for determining
entitlement to Social Security benefits. We may, however, disclose the information provided on this
form in accordance with approved routine uses of the Privacy Act (5 U.S.C. § 552a(b)), which
include but are not limited to the following:
Form HA-539 (12-2015) UF (12-2015)
PRIVACY ACT NOTICE
Collection and Use of Personal Information
1. To enable an agency or third party to assist Social Security in establishing rights
to Social Security benefits and/or coverage;
2. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level;
3. To comply with Federal laws requiring the disclosure of the information from our
records; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity of SSA programs.
We may also use the information you provide when we match records by computer. Computer
matching programs compare our records with those of 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 payments or
delinquent debts under these programs.
A complete list of routine uses for this information is contained in our System of Records Notice
60-0089 (Claims Folders System). Additional information regarding this form and our other system
of records notices and Social Security programs are available from our Internet website at
www.socialsecurity.gov
or at your local Social Security office.
- 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 5 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
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
Paperwork Reduction Act Statement
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