Form Ssa-L-93-Sm (04-11) - Retirement, Survivors And Disability Insurance Form (Page 6 of 7) in pdf

Form Ssa-L-93-Sm (04-11) - Retirement, Survivors And Disability Insurance Form Page 6

Page 6 of 7

RETURN THIS QUESTIONNAIRE

Please send all requested information to:

Social Security Administration

P.O. Box 33021

Baltimore, Maryland 21290-3021

Do not send cash, checks, or money orders to SSA. Tax payments are payable to the Internal

Revenue Service.

PRIVACY/PAPERWORK ACT NOTICE

Missing and Discrepant Wage Reports and Letter Questionnaire

Privacy Act Statement

Collection and Use of Personal Information

Section 205(c)(2)(A) of the Social Security Act, as amended (42 U.S.C. 405(c)(2)(A)), authorizes us to collect this

information. We will use the information you provide to help us to properly credit the earnings records for your

employees. The information you provide on this form is voluntary. However, failure to provide all or part of the

requested information will result in referral of your case to the Internal Revenue Service.

We rarely use the information you provide on this form for any purpose other than for the reasons explained above.

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 for Social Security records (e.g., to the

Government Accountability Office, General Services Administration, National Archives Records

Administration, and the 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 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

agencies 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.

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SSA-95-SM (04-11)

Form Ssa-L-93-Sm (04-11) - Retirement, Survivors And Disability Insurance Form Page 6