Fillable Form Ssa-5666 - Request For Administrative Information (Page 2 of 2) in pdf

ADDITIONAL COMMENTS Use this section for continuation of any answers from page 1, and for any additional

information about this child's records that may help us obtain the information we need to evaluate the child's

functioning.

Phone

Name/Title

Date

(

)

Date

Phone

Name/Title (If more than one person helped complete this form)

(

)

THANK YOU

Privacy Act Statement

Request for Administrative Information Collection and Use of Personal Information

Sections 1614 and 1633 of the Social Security Act, as amended, and 20 CFR 416.924a(a), authorize us to collect this

information. We will use the information you provide to make a decision on the named claimant’s claim.The information you

furnish on this form is voluntary. However, failure to provide the requested information could prevent us from making an

accurate and timely decision on the named claimant’s claim. We rarely use the information you supply for any other purpose

than to make a decision on a claimant’s disability. However, we may use it for the administration and integrity of Social Security

programs. We may also disclose information to another person or to another agency in accordance with approved routine uses,

which include but are not limited to the following:

1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or

coverage; 2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the

Government Accountability Office and Department of Veterans Affairs); 3. To make determinations for eligibility in similar health

and income maintenance programs at the Federal, State, and local levels; and 4. To facilitate 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 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 Systems of Records Notice 60-0089 (Claims Folder Systems). The Notice, additional

information about this form, and any other information regarding our systemsand programs are available on-line at

www.

socialsecurity.gov

or at your local Social Security office.

- This information collection meets the requirements of 44 U.S.C. § 3507, as amended

Paperwork Reduction Act Statement

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 30 minutes to read the instructions,

answer the questions, and collect school records. If you have questions about how to complete the form, contact the

Requesting Office; see page 1, upper left corner for the name, address, and phone number of the Requesting Office. If you

need the address or phone number of the Requesting Office, you can get it by calling Social Security at 1-800-772-1213 (TTY

1-800-325-0778). SEND THE COMPLETED FORM TO THE REQUESTING OFFICE. 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.

Page 2

Form SSA-5666 (01-2016)

Form Ssa-5666 - Request For Administrative Information Page 2

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