Form Ssa-16-Bk - Application For Disability Insurance Benefits - Social Security Administration Page 6

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FOR YOUR INFORMATION
An agency in your State that works with us in administering the Social
Security disability program is responsible for making the disability decision
on your claim. In some cases, it is necessary for them to get additional
information about your condition or to arrange for you to have a medical
examination at Government expense.
Collection and Use of Information From Your Application — Privacy Act Notice/Paperwork Act Notice
The Social Security Administration is authorized to collect the information requested on this form under sections
202, 205, and 223 of the Social Security Act. The information you provide will be used by the Social Security
Administration to determine if you or a dependent is eligible to insurance coverage and/or monthly benefits. You
do not have to give us the requested information. However, if you do not provide the information, we will be
unable to make an accurate and timely decision concerning your entitlement or a dependent's entitlement to
benefit payments.
The information you provide may be disclosed to another Federal, State, or local government agency for
determining eligibility for a government benefit or program, to a Congressional office requesting information on
your behalf, to an independent party for performance of research and statistical activities, or to the Department of
Justice for use in representing the Federal government.
We may also use this information when we match records by computer. Matching programs compare our records
with those of other Federal, State, or local government agencies. Many agencies may use matching programs to
find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even
if you do not agree to it.
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.
PAPERWORK REDUCTION ACT
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
20 minutes to read the instructions, gather the facts, and answer the questions. SEND 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 (TTY1-800-325-0778). 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-16-BK (05-2006)
EF (12-2008)
Page 6

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