Privacy Act Statement
Sections 202, 205, 223, 226, and 806 of the Social Security Act, as amended, 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 making an
accurate and timely decision on your entitlement or a dependent’s entitlement to Social Security benefit payments.
We will use the information to determine your or a dependent’s eligibility for Social Security benefits. We may also share
your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies (or agents on their behalf) for administering income maintenance or health
maintenance programs (including programs under the Social Security Act). Such disclosures include, but are not limited
to, release of information to: Railroad Retirement Board for administering provisions of the Railroad Retirement Act
relating to railroad employment; for administering the Railroad Unemployment Insurance Act and for administering
provisions of the Social Security Act relating to railroad employment; and Department of Veterans Affairs for
administering 38 U.S.C. 1312, and upon request, for determining eligibility for, or amount of, veterans benefits or verifying
other information with respect thereto pursuant to 38 U.S.C. 5106; and
2. To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration
(SSA) in the efficient administration of its programs. We will disclose information under the routine use only in situations
in which SSA may enter into 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.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0059, Earnings
Recording and Self-Employment Income System, 60-0089, entitled Claims Folders Systems, 60-0090, entitled Master
Beneficiary Record, and 60-0321, entitled Medicare Database. Additional information and a full listing of all our SORNs are
available on our website at www.ssa.gov/privacy/sorn.html
.
Paperwork Reduction Act Statement
AFTER YOU RECEIVE
A NOTICE OF AWARD
(AREA CODE)
Your application for Social Security benefits has been
received and will be processed as quickly as possible.
You should hear from us within days after you
have given us all the information we requested. Some
claims may take longer if additional information is needed.
In the meantime, if you change your address, or if
there is some other change that may affect your claim, you -
or someone for you - should report the change. The changes
to be reported are listed below.
Always give us your claim number when writing or calling
about your claim.
If you have any questions about your claim, we will be glad to
help you.
TELEPHONE
NUMBER(S) TO
CALL IF YOU
HAVE A
QUESTION OR
SOMETHING TO
REPORT
SSA OFFICE DATE CLAIM RECEIVED
SOCIAL SECURITY
CLAIM NUMBER
CLAIMAINT
RECEIPT FOR YOUR CLAIM FOR SOCIAL SECURITY MOTHER'S OR FATHER'S INSURANCE BENEFITS
BEFORE YOU RECEIVE
A NOTICE OF AWARD
(AREA CODE)
DECEASED'S SURNAME IF DIFFERENT
FROM CLAIMANT'S
- 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 15 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.
Form SSA-5-BK (10-2018) UF Page 6 of 7