Form SSA-3194 Renewal Certification

Form Approved
OMB No. 0960-0624

Social Security Administration

RENEWAL CERTIFICATION
In Connection With Medical Parking at SSA Headquarters Buildings in Baltimore, MD
To Be Completed Only By Individuals Possessing A Permanent Lane And Space Parking Permit
INSTRUCTIONS: The Social Security Administration (Agency or SSA) offers medical parking as a reasonable accommodation to
employees who are "disabled," as defined by Rehabilitation Act of 1973, as amended, 29 U.S.C. 791, et seq. Based on your prior
application, SSA provided you with a permanent lane and space parking permit, which was valid for a one year period. Before the
expiration of your current parking permit, please complete the below certification and return to the Deputy Director, Office of Protective
Security Services of SSA, P.O. Box 26430, Suite #18 Baltimore, MD 21207, or fax to (410) 965-9676.

1. Name (last, first, middle int.):

2. Last four digits of SSN:

3. Office/Company:

4. Work Schedule:

5. Building/Room No.:

6. Identify Current Parking Space:
Area ________

Renewal Certification

Signature:

Lane _________ Space __________

I hereby certify that the physical or mental impairment for which I received medical
parking has not materially improved and that I still need a lane and space parking
assignment. I understand that if the physical or mental impairment for which I
received medical parking improves, that I will promptly inform the Deputy Director,
Office of Protective Security Services, and that I may no longer be eligible for a lane
and space parking assignment. I further certify that if I leave the employ of the
Agency, that I will promptly return this permit to the Division of Security Services.

Date:

Telephone Number:

PRIVACY ACT STATEMENT: SSA is authorized to collect the information requested on this form by the Federal Property and
Administrative Services Act of 1949, as amended, 63 Statute 377, 390 (40 U.S.C. 471, 486 and 41 CFR 101-20.104-2), and
Rehabilitation Act of 1973, as amended, 29 U.S.C. 791, et seq. Executive Order 9397 (November 22, 1943) authorizes use of the Social
Security Number. SSA uses this information to provide standards for apportioning and assignment of handicapped parking spaces on
SSA managed, controlled or assigned property, and to allocate and check parking spaces assigned to handicapped personnel and others.
SSA also uses it to determine reasonable accommodations.
You do not have to give SSA this information. Your submission is voluntary. SSA, however, will use the information provided by you
to facilitate the processing of your request. Therefore, the failure to fully complete the form and provide the requested information may
make it impossible for SSA to process your request. SSA will not make any disclosure of this information to agencies or individuals
outside this department unless the law permits, you provide written consent, or it is otherwise required. For example, SSA may disclose
the information to the Department of Justice in the event of litigation where the defendant is SSA, any SSA component, or any SSA
employee in his or her official capacity; to a congressional office requesting information on your behalf; and to volunteers or individuals
working under a service contract and other individuals performing functions for SSA if they need access to the records for the
performance of their assigned agency functions. You may contact the Deputy Director, Office of Protective Security Services at (410)
966-8814 for further explanation as to the reasons why the SSA may use or disclose information about you.
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 5 minutes to read the instructions, and answer the
questions. You may send comments on our time estimate above to: SSA 6401 Security Boulevard, e, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.

Form SSA-3194 (X-2008)