For The Applicant
We are authorized to collect the information on this form under sections 202(a), 205(a), and 1872 of the Social Security Act, as amended (42 U.S.C. 402(a), 405(a), and 1395(ii)). While it is voluntary, except in the circumstances explained below, we may not pay benefits unless we receive an application. Your response is mandatory where the refusal to disclose certain information affecting your right to payment would reflect a fraudulent intent to secure benefits not authorized by the Social Security Act. We need the information on this form to determine if you and your dependents are entitled to insurance coverage and/or monthly benefits. If you do not provide all or part of this information, it could prevent us from making an accurate and timely decision on your claim or your dependent's claim, and could result in the loss of some benefits or insurance coverage.
The information you furnish on this form is almost never used for any purpose other than to determine if you and your dependents are entitled to insurance coverage and/or monthly benefits. However, there is a possibility that for the administration of the Social Security programs or for the administration of programs requiring coordination with the Social Security Administration, we may disclose information to another person or to another agency as follows:
To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;
To comply with federal laws requiring the release of information from Social Security records (e.g., to the General Accountability Office and Department of Veterans' Affairs); and
To facilitate statistical research and audit activities necessary to assure the integrity and improvement of the Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).
We may also use the information you provide without your consent in automated matching programs. These matching programs are computer comparisons of our records with records kept by other Federal agencies or 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 payments or delinquent debts under these programs.
Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.
For the Third Party Filer
The Social Security Administration (SSA) is allowed to collect the information you provide about yourself as a third party filer on this application under Section 205 of the Social Security Act. We need this information to identify who you are as the third party filer and to provide it to the claimant on the summary sheet of the application. Giving us this information is voluntary. However, without it we may not be able to process the application.
While the information you furnish on this form would almost never be used for any purpose other than the intended use of this form, such information may be disclosed by SSA as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes using the information as necessary for administrative purposes or as authorized by routine uses in the applicable Privacy Act system of records.
Explanations about possible reasons why information you provide us may be used or given out are available upon request from any Social Security office.