Form Ssa-1199-Po-Op1 - Direct Deposit Sign-Up Form (Poland) Page 3

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Privacy Act Statement
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, authorizes us to collect this information. We will use the information you
provide to process Social Security benefit payments with your financial institution and/or its agent.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may affect the
processing of this form and may delay or prevent the receipt of your benefit payments through the Direct Deposit/Electronic
Funds Transfer Program.
We rarely use the information you supply for any purpose other than to process Social Security benefit payments with your
financial institution and/or its agent. 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 statistical research, audit, or investigative activities necessary to assure the integrity and improvement of
Social Security programs (e.g., to the Bureau of the Census and to private entities under contract with us).
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.
A complete list of routine uses for this information is available in our System of Records Notices entitled, Claims Folders Systems,
60-0089 and Master Beneficiary Record, 60-0090. These notices, additional information regarding this form, and information
regarding our programs and systems, are available on-line at
or at your local Social Security office.
Form SSA-1199-PO-OP1 (09-2015)


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