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Social Security Number:
Privacy Act Statement
Collection and Use of Personal Information
Sections 221, 223(d)(4), 1612(b)(4)(B), and 1614(a)(3)(D) of the Social Security Act, as
amended, authorize us to collect this information. We will use the information you
provide to determine whether the employee's work activity was an unsuccessful work
attempt or whether it is/was subsidized.
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 benefit 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); and,
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 complete 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
Folder System and 60-0103, entitled, Supplemental Security Income Record and
Special Veterans Benefits. 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 share the information you provide to other health agencies through computer
matching programs. Matching programs compare our records with records kept by
other Federal, State, or local government agencies. We use the information from these
programs 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.
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 (OMB) control number. We estimate that it will
take about 15 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401.
Form SSA-3033 (01-2016) UF (01-2016)