Form SSA-8510 Authorization for the Social Security Administration to

SOCIAL SECURITY ADMINISTRATION

AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION

TO OBTAIN PERSONAL INFORMATION

Authorizing Person (person about whom information is being requested) Social Security Number

Claimant/Beneficiary (If other than authorizing person) Claimant’s/Beneficiary’s Social Security Number

I authorize any public or private custodian of records to disclose to the Social Security Administration any records or information about me. In case of a minor or incapable person, I, as guardian or representative, authorize the same disclosure of records about the person I represent.

Authorizing Person’s Signature Date

SIGN

H ERE

Mailing Address City and State ZIP Code

Y our 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)

COLLECTION AND USE OF INFORMATION ON YOUR CONSENT FORM-

PRIVACY ACT NOTICE

The Social Security Administration is authorized to collect the information on your consent form under sections 205(a) and 163(e) of the Social Security Act, as amended (42 U.S.C. 405 and 42 U.S.C. 1383(e)). Giving us the information on this form is voluntary. You do not have to do it but benefits may not be payable unless you give us this information.

The Social Security Administration will use this form to get information to decide eligibility for payments. We may routinely give out the information obtained without your consent if:

1. We need to get more information to decide eligibility for benefits;

2. An agency needs this information to decide eligibility for a health or income program such as Supplemental Security Income (SSI), State supplementary payments, food stamps, Medicaid, energy assistance, Veterans benefits, railroad unemployment insurance, or Basic Educational Opportunity Grants;

3. A Federal law requires that we give out this information;

4. Your congressman or the President’s Office needs this information to answer questions you ask them;

5. Someone needs this information to do statistical research or audit reports for us related to the Social Security programs;

6. or, The Department of Justice needs the information to represent the Federal Government in a court suit related to an SSA program.

These and other reasons why information about you may be use or given out are explained in the Federal Register. If you would like more information about this, get in touch with any Social Security Office.

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 10 minutes to read the instructions, gather the facts, and answer the questions. Send only comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.

Form SSA-8510 (9-87) *U.S. Government Printing Office: 1995- 387-008/20192