Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 205(j) of the Social Security Act, as amended, authorize us to collect this information.
We will use the information you provide to make a determination regarding the beneficiary's need for a
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
management of benefits. 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 form 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 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 Folders Systems; and, 60-0222, entitled Master
Representative Payee File. Additional information about these and other system of records notices and our
programs is available online at www.socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in our computer matching programs. Matching programs
compare our records with records kept by 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 incorrect payments or delinquent debts under these
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 10 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 -
Form SSA-787 (11-2015) UF (11-2015) Page 3