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Form Ssa-5-Inst - Reporting Responsibilities For Mother'S Or Father'S Insurance Benefits Page 2

Collection and Use of Information From Your Application

Privacy Act Notice

The Social Security Administration (SSA) is authorized to collect the information on this form under sections 202, 205, and 223 of the

Social Security Act. The information you provide will be used by SSA to determine if you or a dependent is eligible to insurance

coverage and/or monthly benefits. While completion of this form is voluntary, failure to provide all or any part of the requested

information may effect our ability to make an accurate and timely decision concerning your entitlement or a dependent's entitlement to

benefit payments.

The information you furnish on this form may be disclosed by SSA as generally permitted under 5 U.S.C.§ 522a(b) of the Privacy Act, as

amended. This includes using the information: (1) to assist Social Security in establishing the right of an individual to Social Security

benefits; (2) to facilitate statistical research and audit activities necessary to assure the integrity and improvement of the Social Security

programs; and (3) to comply with Federal laws requiring the release of information from our records.

SSA may also use the information you give us 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 SSA to do this even if you do not agree to it.

Explanation about reasons why information you provide us may be used or provided to other agencies are available upon request from a

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 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. 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-5-INST (07-2009) EF (07-2009)

Form Ssa-5-Inst - Reporting Responsibilities For Mother'S Or Father'S Insurance Benefits Page 2