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PRIVACY ACT NOTICE

Section 204(d) of the Social Security Act, as amended, authorizes us to collect this information. The information you provide will

enable us to account for the beneficiary's payments and ensures that the beneficiary's needs are being met. Your response is

voluntary; however, failure to provide all or part of the requested information may prevent an accurate and timely decision on any

claim filed, or could result in the loss of benefits.

We rarely use the information provided on this form for any purpose other than determining entitlement to benefit payments.

However, we may disclose the information provided on this form in accordance with approved routine uses, which include but are

not limited to the following:

To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration

in the efficient administration of its programs;

To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government

Accountability Office and Department of Veteran's Affairs);

To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local

level; and,

To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social Security

programs.

We may also use the information you provide in 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 and administered benefit programs and for repayment of payments or

delinquent debts under these programs.

A complete list of routine uses for this information is available in System of Record Notice 60-0090. The notice, additional

information regarding this form, and information regarding our programs and systems are available on-line at

or at your local Social Security office.

Paperwork Reduction Act Statement - 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. The office is 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-1724-F4 (01-2010) EF (01-2010)

Form Ssa-1724-F4 - Claim For Amounts Due In The Case Of A Deceased Social Security Recipient Page 3