Form SSA-8001-BK (09-2019) UF Page 12 of 12
Privacy Act Statement
Collection and Use of Personal Information
Section 1631(e) of the Social Security Act, as amended, allows us to collect this information. Furnishing this information
is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any
We will use the information to determine eligibility for Supplemental Security Income (SSI) payments. We may also
share your information for the following purposes, called routine uses:
• To specified business and other community members and Federal, State, and local agencies for verification of
eligibility for benefits under section 1631(e) of the Act; and
• To State agencies to enable them to assist in the effective and efficient administration of the SSI program.
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) 60-0089, entitled
Claims Folders Systems, as published in the Federal Register (FR) on April 01, 2003, at 68FR 15784, and 60-0103,
entitled Supplemental Security Income Record and Special Veterans Benefits, as published in the FR on January 11,
2006, at 71 FR 1830. Additional information, and a full listing of all of our SORNs, is available on our website at
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 19-20 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