Revisions to the SSA-4641

Form Approved

Social Security Administration OMB No. 0960-0293

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

account number(s)

□ joint account, □ direct deposit □ joint account, □ direct deposit □ joint account, □ direct deposit

______________________________, ________________________________, _____________________________

The Social Security Administration will request records to determine initial or continuing eligibility and the accuracy of the payment for Supplemental Security Income benefits. I understand that any information obtained will be kept confidential and that:

1. I have the right to revoke this authorization at any time before any records are disclosed; and

2. If I am an applicant or recipient, failing to provide or revoking my authorization will result in a denial or suspension of benefits; and

3. If I am a person whose income and resources the Social Security Administration considers as being available to an applicant or recipient, failing to provide or revoking my authorization may result in a denial of benefits for the applicant or a suspension of benefits for the recipient; and

4. The Social Security Administration may request all records about me from any financial institution, whether or not listed above; and

5. I have the right to obtain 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

6. This authorization is not required as a condition of doing business with the financial institution named above.

I authorize any custodian of records at this financial institution to disclose to the Social Security Administration any records about my financial business or that of the person named above whom I legally represent or whose benefits I manage.

customer’s signature/authorization	mailing address	date
legal representative’s signature /authorization	legal representative’s mailing address	date

Your authorization does not ordinarily have to be witnessed. However, if you have signed by mark (X), two witnesses to the signing who know you must sign below giving their full addresses.

1.  signature of witness	2.  signature of witness
address (Number, Street, City, State, Zip Code)	address (Number, Street, City, State, Zip Code)

I CERTIFY that the applicable provisions of the Right to Financial Privacy Act of 1978 (12U.S.C. 3401-3422) have been complied with in this request. Pursuant to the Right to Financial Privacy Act of 1978, good 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.

authorization of social security administration representative	telephone no (include area code)	date
address

Customer's Name:

Social Security Number:

REQUEST FOR RECORDS

This request is authorized by section 1631(e)(1)(B) of the Social Security Act, as amended. While you are not required to respond, your cooperation will help us determine the eligibility of the applicant or recipient named above for Supplemental Security Income benefits. The customer's authorization for release of the information contained in your records appears on page one of this form.

Please provide information for the period ______________ through _____________ for the account number(s) listed above and any others held (either individually or jointly) by the above named customer.

SSA REMARKS

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FOR COMPLETION BY THE FINANCIAL INSTITUTION REPRESENTATIVE

INSTRUCTIONS FOR COMPLETION

• Refer to page one for information concerning the accounts to be verified. If the customer owns other accounts that are not listed, please provide information on those accounts for the time frame requested.

• We need account information even if the account has been closed or the account number has changed.

• Spaces are available for up to three accounts. If there are more than three accounts, please provide information on a separate sheet of paper.

• Please include at the end of this form the name of the financial institution representative providing account information.

• Please return this form and all supporting materials to the Social Security Administration in the postage free return envelope provided.

• If no accounts are located, check the box below where indicated.

	ACCOUNT 1	ACCOUNT 2	ACCOUNT 3
TYPE OF ACCOUNT1
ACCOUNT NUMBER
NAME(S) ON AND EXACT ACCOUNT DESIGNATION

¹Checking, Savings, Time/Certificate of Deposit, Keogh, IRA, UGMA/UTMA, Escrow, Etc.

 No accounts were located for this customer.

• Copies of account records may be submitted in lieu of entering data below.

• For all accounts, provide opening balances as of the first day of the month for each account, for each month listed in the period.

 Unless this box is checked, do not provide interest paid or credited during each month.

Customer's Name:

Social Security Number:

	ACCOUNT 1		ACCOUNT 2		ACCOUNT 3
Month/Year	Balance	Interest Paid	Balance	Interest Paid	Balance	Interest Paid

Name of Financial Institution Representative Phone Number

( )

Date

REMARKS

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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 control number. We estimate that it will take about 6 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401, Send only comments relating to our time estimate to this address, not the completed form.

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 benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.

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

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Form SSA-4641-U2 4