To view the form, go to SSA-437–BK
Paperwork reduction act
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of Section 3507 of the Paperwork Reduction Act of 1995. We
may not conduct or sponsor, and you are not required to respond to, a collection of
information unless it displays a valid OMB control number.
Time it takes to complete this form
We estimate that it will take you about one hour to provide the information. This
includes the time it takes to read the instructions, gather the facts and complete
Uses of personal information for investigations
The information collection is authorized by 5 U.S.C. §301; 29 U.S.C. §791 et. seq.;
42 U.S.C.§§902(a)(5), 1305 note. Those statutes require the agency not to discriminate
on the basis of disability and authorize the Commissioner establish policies to prohibit
SSA and SSA employees from discriminating based upon race, color national origin,
sex, age, religion, or retaliation in any program or activity conducted by SSA.
There are two federal laws governing personal information given to all Federal agencies,
including the Office of the General Counsel (OGC):
The Privacy Act of 1974, (U.S.C. Sec. 522a); and
The Freedom of Information Act, (5 U.S.C. Sec. 522).
The Privacy Act protects individuals from misuse of personal information held by the Federal government.
The law applies to records that are kept and that can be located by the name, social
security number, or other personal identification system.
Personal information will be used for authorized civil rights activities and other
Privacy Act routine uses. Generally, OGC will not release information unless the person
who supplied the information submits a written consent, or unless release is required
under the Freedom of Information Act or other Federal statute or regulation. However,
OGC can refer complaints to other Federal agencies, such as the Department of Justice,
the Department of Labor and the Equal Employment Opportunity Commission, without the
person's prior consent. This authority is provided under the “routine use” exception of the Privacy Act.
Information submitted to OGC may also be given to other government agencies, such
as the Department of Justice, when as SSA components has violated civil rights laws
A person cannot be required to give personal information to OGC, and no sanctions
will be imposed on person who deny our request. However, if OGC cannot get information needed to investigate allegations of discrimination,
it may have to close the investigation.
The Freedom of Information Act (FOIA) gives the public the right of access to files and records of the Federal government.
With some exceptions, the Social Security Administration must honor FOIA request,
though our policy is to do so without releasing a person's name or other personal
identification. SSA is generally not required to release documents if the release
would interfere with SSA's ability to complete its work; as, for example, during an
investigation or enforcement proceeding. Also any Federal agency may refuse a request
for files or records if the release would be an unnecessary invasion of an individual's