Fillable Form SSA-731 (12-2020): Notice to Electronic Information Exchange (U.S. Social Security Administration)

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Form SSA-731 (12-2020): Notice to Electronic Information Exchange (U.S. Social Security Administration)

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Form SSA-731 (12-2020)
Social Security Administration
Page 1 of 4
OMB No. 0960-0820
Notice to Electronic Information Exchange Partners to Provide Contractor List
The Social Security Administration (SSA) requires any organization with an electronic data exchange
agreement, to provide the SSA Regional Office contact a current list of contractors and/or agents who have
access to SSA data upon request and the attached Agency Attestation of Contractor Use Form.
For the purpose of this form, the term "organization" refers to state or local agencies, territories, tribes, or
other entities that have a data exchange agreement with SSA.
Data exchange agreements include:
• Computer Matching Agreement (CMA)
• Information Exchange Agreements for federally funded benefit programs (IEA-F)
• Information Exchange Agreement for state funded benefit programs (IEA-S)
• Reimbursable Information Exchange Agreement (R-IEA)
• State Transmission/Transfer Component (STC) agreement
• Social Security Online Verification (SSOLV) agreement
• Memorandum of Understanding (MOU)
Please complete the following Agency Attestation of Contract Use Form and Contractor List Form.
(State)
(Name of Organization)
Government Non-Government
Federal
Local
Foreign
Other (Please specify)
Tribal
State
Form SSA-731 (12-2020) Page 2 of 4
Agency Attestation of Contractor Use Form
(Name of Organization)
, certifies that the contractors/agents in the Contractor
List Form are currently under contract with and act on behalf of the organization, to process, maintain,
transmit, store, or destroy SSA data.
All contractors/agents listed in the Contractor List Form:
• have been provided with a copy of the SSA/
(Name of Organization)
• are in compliance with the safeguards and dissemination procedures defined in the agreement.
,
data exchange agreement prior to the initial disclosure of SSA data; and
Within 60 days of a new contractor/agent having access to SSA data or an existing contractor/agent no
longer having access to SSA data, the
(Name of Organization)
, will notify the
SSA Regional Office contact in writing with an updated Agency Attestation of Contractor Use Form and
Contractor List Form.
Date:
Title:
Does your organization utilize any contractors with access to SSA data?
Yes No
• If no, complete Section 2, sign the form at the bottom of this page and return the form to SSA.
• If yes, complete Sections 1 and 2 and the Contractor List Form. Sign the form at the bottom of this page
and return the form to SSA.
Print Name:
SECTION 1
SECTION 2
Signature (Approving Official) :
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signature
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Form SSA-731 (12-2020) Page 3 of 4
Contractor List Form
Organization Name:
Contracting Company Name
Contractor/Employee Name
(First, Last)
Position/Duties Location (City & State)
Form SSA-731 (12-2020) Page 4 of 4
Privacy Notice for Collection of Information
Sections 44 U.S.C. §�3554, 42 U.S.C. § 1306, and 20 C.F.R. § 401.145 allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent us from sharing SSA data via an information exchange agreement (IEA).
We will use the information you provide to conduct a compliance review. We may also share your
information for the following purposes, called routine uses:
· To students volunteers, individuals working under a personal services contract, and other workers
who technically do not have the status of Federal employees, when they are performing work for the
Social Security Administration (SSA), as authorized by law, and they need access to personally
identifiable information in SSA records in order to perform their assigned agency functions; and
· To contractors and other Federal agencies, as necessary, for the purpose of assisting the SSA in the
efficient administration of its programs. We will disclose information under this routine use only in
situations in which SSA may enter a contractual or similar agreement with a third party to assist in
accomplishing an agency function relating to this system of records.
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.
Additional information, and a full listing of all of SSA systems of records and approved routine uses, is
available at www.ssa.gov/privacy.
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 20 minutes to read the instructions, gather the facts, and answer the questions. Send
only comments regarding this burden estimate or any other aspect of this collection, including
suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401
Paperwork Reduction Act Statement -
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Form SSA-731 (12-2020): Notice to Electronic Information Exchange (U.S. Social Security Administration)

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Completed 26 January 2021

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