Form Ssa-5665-Bk - Teacher Questionnaire Page 2
Download a blank fillable Form Ssa-5665-Bk - Teacher Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ssa-5665-Bk - Teacher Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10The Privacy Act Statement
Teacher Questionnaire
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 our making an accurate and
timely decision on the named claimant’s claim. We rarely use the information you supply for any
purpose other 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 level; and
4. To facilitate audit or investigative activities necessary to ensure 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 systems and programs 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 40 minutes to read the instructions, gather the facts, and
answer the questions. 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 for 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.
PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM
Form SSA-5665-BK (09-2011) ef (09-2011)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal