Student Reporting Form

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 202(d), 202(x), 203(h), and 205(a) of the Social Security Act, as amended, allow us to
collect your information, which we will use to determine benefits eligibility. Providing this
information is voluntary, but not providing all or part of the information may prevent us from
making an accurate and timely decision. As law permits, we may use and share the information
you submit, including with other Federal agencies, contractors, and others, as outlined in the
routine uses within System of Records Notice 60-0089, available at www.ssa.gov/privacy. Your
information may also be used in computer matching programs for Federal benefits eligibility and
to recoup debts under these programs.

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
(OMB) control number. We estimate that it will take about 6 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.