Form SSA-4641-U2 Authorization for the Social Security Administration to

Form Approved
OMB No. 0980-0293

Social Security Administration

AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN ACCOUNT
RECORDS FROM A FINANCIAL INSTITUTION AND REQUEST FOR RECORDS
CUSTOMER'S NAME

SOCIAL SECURITY NUMBER

NAME AND ADDRESS OF FINANCIAL INSTITUTION

APPLICANT/RECIPIENT IF OTHER THAN CUSTOMER

SOClAL SECURITY NUMBER

ACCOUNT NUMBER($) (INDIVIDUAL OR JOINT)

A request for records will be made by the Social Security Administration t o determine initial or continuing eligibility and
the accuracy of payment for Supplemental Security Income benefits. I understand that any information obtained will be
kept confidential and that:
1. This authorization is valid for up to 3 months from the date of my signature; and
2, 1 have the right t o revoke this authorization a t any time h f o r e any records are disclosed; and
3 , The Social Security Administration is requesting all records appearing o n the attachment t o this authorization,
whether or not listed above; and
4. 1 have a right to a copy of the record which the financial institution keeps concerning the instances when it has
disclosed records to a Government authority unless the records were disclosed because of a court order; and
5, This authorization is not required as a condition of doing business with the financial institution named above; and
6 , As a customer, my authorization is'voluntary; however, if I am an applicant or recipient, failure to provide my
signature below may result in a suspension or loss of benefits.
I authorize any custodian of records at the financial institution named a h to disclose to the b i a l Seeurity Administration any
records about my financial business or that of the person named above whom I legally represent or whose benefit I manwe.
CUSTOMER'S SIGNATURE

DATE

MAILING ADMlESS

I

LEGAL REPRESENTATIVE'S OR REPRESEWATWE PAYEE'S SIGNATURE

REPRESENTATIVE'S MAlUNG ADOAESS

I

IDATE

I

Your authorization does not ordinarlly have to be witness&. However, if you have signed by mark (X), two witnesses to the slgning
who know you must sign below giving thdr full addresses.
1 . SIGNATURE OF WITNESS
2. SIGNATURE OF WITlUESS
ADDRESS (Number, Street, Clty, State, Zip Code)

ADDRESS ( N u h r , Street, City, State, tip Code)
I

I CERTIFY that the applicable provislons of the Right to Fhancial Privacy Act of 1978 I1 2 U.S.C. 3401-3422) have b w n complied
with in this request. Pursuant to the Right to Flnanclal Rlvacy Act of 7978, gooel faith reliance upon this certification relieves your
institution and its employees and agents of any possible liability to the customer in connection with the disclosure of these financial
records.
SIGNATURE OF SOCIAL SECURITY ADMINISTRATION REPRESENTATIVE

ADDRESS

Form $$A-142

(06.2003) EF (04-2006)

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TELEPHONE NO. (Include area code)

DATE

INFORMATION FOR THE FINANCIAL INSTITUTION
Part A: The type of account, account number,
and designation exactly as shown on
the account.

WHY THIS INFORMATION IS NEEDED

To ensure that supplemental security income (SSI)
payments are made only to eligible persons, it is
sometimes necessary to verify allegations about financial
institution accounts. Experience has shown that the
verification you provide is directly responsible for reducing
the number of incorrect payments and results in savings to
the taxpayer.

part B: 1. The opening balance(s1 as of the
first day of the month(s) listed. If your
records show only closing balances,
enter the closing balance for the last
day of the previous month.

2. The amount of interest paid or
credited the account(s) in each month
listed.

Most of the time we use the customer's records, but
sometimes we check with you to:

D i s c o v e r other accounts which may not have been
reported to us. SSA studies confirm that unreported
accounts are discovered most often where a customer
acknowledged having an account.
Find out the exact balance of all accounts as of the
first day of the month. Since we periodically review an
individual's circumstances to ensure eligibility for SSI,
we sometimes ask for balances covering more than a
year.

Paperwork Reduction Act Statement - This information
collection meets the requirements of 44 U.S.C. 5 3507, as
amended by Section 2 of the Paperwork Reduction Act of
1995. You do not need to answer these questions untsss
we display a valid Office of Management and Budget controf
number. We estimate that it will take about 6 minutes to
read the Instructions, gather the facts, and answer the
questions. SEND THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFRCE. The offlce Is listed under U. S.
Government sgendes in your telephone directory or you may

Ask about interest payments because SSI is a needs
based program and we must know about all available
income to determine if it affects eligibility or payment.

IMPORTANT REMINDER ITEMS
Page 1: Make
sure
that
the
customer(s)
(or
representative) and the SSA representative have
signed and dated the form. If a signature is
missing, call the SSA office shown.

call SDcial Security at 1-800-772-1213. You may send
comments on our time estimate above to: SSA. 1338
Annex Buildng, Bakimore, MD 2 7235640 7. Send only
wmmenfs relating to our time estlinate to this addnrss, not
th%cornpleled bm.

Page 3: Part I--Read this lo find out which accounts need
to be verified. If the customer owns other
accounts which are not shown in part I. please
also provide the information needed about these

We may also use the information you give us when we
match records by computer. Matching programs compare
our records with those of other Federal, State, or local

government agencies. Many agencies may use matching
programs to find or prove that a person qualifies for beneflts
paid by the Federal government. The law allows us t o do
this even if you do not agree t o it.

accounts.
Part Il--Read this t o find out what information is needed to
verify those accounts.

Explanations about these and other reasons why information
you provide us may be used or given out are avaiilable in
Social Security offices. If you want t o learn more about this,
contact any Social Security office.

Page 4: Use this page to furnish the verifying information.
Note: The information is needed even if the
account has been closed. Please show the
following,formation in:

PLEASE BE SURE TO SIGN AND DATE THE FORM AND RETURN IT IN THE ENVELOPE PROVIDED.
ADDITIONAL INFORMATIONIREMARKS F R O M SSA

Form SSA-4841-U2 (06-2003)EF (04-2005)

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REQUEST FOR RECORDS

PART I - FOR COMPLETION BY THE SOCIAL SECURITY REPRESENTATIVE
Customer's Name

Customer's Social Security N u m b r

Financial Institution Name and Address

AppllcantlRecipient If Not Customer

Social Security Numbsr
I

Account Murnberts) (Individual or Joint)

through
for the
The financial institution is requested to provide information In Part I1for the period
account number(s1 listed above, whether "active" or "inactlvelclosed." and any others, such as certificates of deposit, etc., held
(individually or jointly) by the above named customer or applicanthecipient.

PART I1 - FOR COMPLETION BY THE FINANCIAL IMSTITUTION REPRESENTATIVE
This request is authorized by sections 1631{e)(l)IB), 1102, and 403j of the Social Security Act, as amended. White you
are not required to respond, your cooperation will help us determine the eligibility of the applicant or recipient named
below for Supplemental Security Income benefits. The customer's authorization for release of the information contained
in your records appears on the attachment to this form.
INSTRUCTIONS FOR CQMPLETION:
R e f e r to Part I above for information about the accounts to be verified

mSpaces are available for up to three accounts. If there are more than three accounts, provide information in the
"Remarks" section or attach a separate sheet of paper, Note: copies of bank records, including computer printouts.
are accepiable in lieu of manual entries on the form.
IN ALL CASES, A FINANCIAL INSTlTUf ION REPRESENTATIVE'S SIGNATURE MUST APPEAR IN THE SPACES
PROVIDED AT THE END OF THIS FORM. A postage free return envelope is enclosed for your convenience.
If no accounts are located, check box in section A, page 4, and sign where indicated.
REMARKS

Form SSA-464'142 (06-2003)EF (04-2005)

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Customer's
Name:
A.

ACCOUNT 1

Social Security
Number:
ACCOUNT 2

ACCOUM 3

Type of Account

Account Num bar

Narnets) On

end Exact
Account
Designation

0 No accounts were located for this customer.
"Checkina. Savinas, TimaiCertificate of Deoosit. IRA. Kewh. Trust Etc.
8. Provide the information in the box(es1 checked for the months indicated. Copies of account records
may be submitted in lieu of entering data b l o w .
1. Opening Balance(s1As Of the First Day of the Month for Each Account (or Balance on the Close
of Business of the Last Day of the Previous Month).

2. The Amount of Interest Paid or Credited During Each Month.

I dsclwe under penalty of perjury that I have examined dl the lnformatlon on thls farm, and on any
accompanying statemem or f o m , and It is true and correct to the best of my knowledge.
Phone N u m k

S i r s of Rmrtcid lnaitutbn Representative

1
Date
Form SSA4WlY2 (06-20033 EF 104-2006)

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