Form Ssa-7163a-F4 - Supplemental Statement Regarding Farming Activities Of Person Living Outside The Usa Page 4
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4Privacy Act Statement
Collection and Use of Personal Information
Sections 403(b), 403(c), and 405(a) of the Social Security Act, as amended, authorize us to collect this
information. The information you provide will be used to confirm past and continuing entitlement to benefits
and to determine whether such benefits are subject to deductions.
The information you furnish on this form is voluntary. However, failure to provide this requested information
could prevent an accurate and timely decision on your claim and could result in the loss of some benefits.
We rarely use the information you supply for any purpose other than for making a determination about your
continuing entitlement to benefits. 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 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 private concerns under
contract to Social Security).
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 Systems of Records Notices entitled,
Master Beneficiary Record, 60-0090 and Supplemental Security Income Record, 60-0103. 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.
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 60 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-7163A-F4 (08-2011) EF (08-2011)
PAGE 4
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