Ssa 3033 Form – Fill Out and Use This PDF

Form SSA-3033 (08-2021) UF	Page 2 of 5

Social Security Number:

What We Need You To Do

Please havedirect supervisor or another person having direct knowledge of

the employee's work activity complete the work activity questionnaire. We would appreciate it if you would complete, sign and return the questionnaire to this office within 7 days using the enclosed envelope. If you have any questions, or if you would rather provide this information over the phone,

please call		and ask for	.

Thank you for your time and assistance.

Manager/Adjudicator Name

Position Title

Enclosure:

Work Activity Questionnaire

Form SSA-3033 (08-2021) UF

Page 3 of 5

Social Security Number:

Privacy Act Statement

Collection and Use of Personal Information

Sections 221, 223(d), 1612(b)(4), and 1614(a)(3) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any claim filed.

We will use the information you provide to validate unsuccessful work attempts and subsidies, and to determine benefits eligibility. We may also share the information for the following purposes, called routine uses:

•To contractors and other Federal agencies, as necessary, for the purpose of assisting us in the efficient administration of our programs. We will disclose information under this routine use only in situations in which we may enter into a contractual or similar agreement to obtain assistance in accomplishing an SSA function relating to this system of records, and

•To claimants, prospective claimants (other than the data subject), and their authorized representatives or representative payees, to the extent necessary to pursue Social Security claims; to representative payees, when the information pertains to individuals for whom they serve as representative payees, for the purpose of assisting us in administering representative payment responsibilities under the Social Security Act; and to representative payees, for the purpose of assisting them in performing their duties as payees, including receiving and accounting for benefits for individuals for whom they as payees.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089, Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422; 60-0090, Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826; and

60-0103, Supplemental Security Income Record and Special Veterans Benefits, at 71 FR 1830. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.

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 15 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.