Form SSA-104 Claimant Travel Reimbursement Request

Form Approved
OMB No. 0960-0752

Social Security Administration

CLAIMANT TRAVEL REIMBURSEMENT REQUEST
You may be reimbursed for travel related expenses to the consultative examination and/or testing location(s). Please
complete, sign and return this form within 10 days after your appointment date along with the appropriate receipts
(described below) to the “Return To” address listed below. Upon receipt of the completed form and appropriate
receipts, travel expenses will be paid based on the round-trip distance between your address and the appointment
location (shown below). If you have any questions or need assistance, please call [800 NUMBER] [CASE MANAGER’S
EXTENSION]. Travel reimbursement is authorized in accordance with SSA’s regulations for claimant travel and the
Federal Travel Regulation.
Return To:

Social Security Administration
[Office name placeholder]
Attn: [CASE MANAGER’S NAME]
PO Box 32926
Baltimore, MD 21241-2926

CONSULTATIVE EXAMINATION (CE) INFORMATION
Service Request Number:

[SERVICE REQUEST NO.]

Name:

[CLAIMANT’S NAME]

Address:

[CLAIMANT’S ADDRESS], [CLAIMANT’S CITY ,ST, ZIP]

CE Provider’s Name:

[VENDOR’S NAME]

Appointment Location:
Appointment Date:

[VENDOR’S ADDRESS], [VENDOR’S CITY ,ST, ZIP]
[APPOINTMENT DATE]
Appointment Time: [APPTMT TIME]

TRAVEL EXPENSE INFORMATION
If you use a privately-owned vehicle to travel to the appointment, we will reimburse you at the current mileage rate in
accordance with federal regulations. If you travel by mass transportation (e.g., bus, subway, etc.) you will be
reimbursed at the customary rate. If you require unusual travel arrangements (e.g., taxi, plane, train, medically
equipped vehicle, or any other mode of transportation other than privately-owned vehicle.), you must contact the Case
Manager before your appointment to request pre-approval for travel reimbursement. Failure to obtain pre-approval
may result in you not being eligible for reimbursement for unusual travel expenses. For payment information,
please call 1-800-582-6041.
Please complete each item for which you are requesting reimbursement.

Please indicate your round trip mileage: I traveled _____________ miles by privately-owned vehicle.
If you were required to pay any tolls, amount paid in tolls:

$________________

If you were required to pay for parking, amount paid in parking:

$________________

If you traveled by any other means of transportation, please complete the section below and attach the required receipts.
If you require special travel arrangements, you must obtain pre-approval in order to request reimbursement.
Enter the name of the person that approved this travel and date approved:
____________________________________
________________________
Name
Date
If you required unusual travel expenses (e.g., taxi, train, bus, plane, or any other mode of transportation other than
privately-owned vehicle), enter the type of transportation used and the amount paid. YOU MUST ATTACH RECEIPTS.
I traveled by ___________________________________ (taxi, train, bus, etc.) and paid $_________ for transportation.
Please explain why this mode of transportation was necessary:
_______________________________________________________________________________________________
TOTAL EXPENSES: Enter your total travel expenses combined (e.g., tolls, parking, other related expenses).
$_____________
Form SSA-104 (12-2007)

1

Form Approved
OMB No. 0960-0752

Social Security Administration
CLAIMANT SIGNATURE

I declare under penalty of perjury that I have examined all the information I provided on this form,
and on any accompanying statements or forms, and it is true and correct to the best of my knowledge.
I understand that anyone who knowingly gives a false or misleading statement about a material fact in
this information, or causes someone else to do so, commits a crime and may be sent to prison, or may
face other penalties, or both.
_________________________________________
Signature

___________________
Date

SOCIAL SECURITY ADMINISTRATION CERTIFICATION (SSA USE ONLY)
Certification of Payment: The travel information has been verified and reimbursement approved.

[CASE MANAGER’S NAME]

CM Signature

Date

Authorization of Payment: The travel payment has been issued for $__________ on ___________, check # __________.

Cashier Signature

Date

See Revised Privacy Act
PRIVACY ACT NOTICE Statement
The information requested on this form is authorized by the Social Security Act, Title 20 CFR
404.999a, 404.999b, 404.999c, and 404.999d. You may be reimbursed for your travel related
expenses to and from your consultative examination and/or test. We need to know how much you
paid in travel expenses in order to reimburse you the correct amount. The information you provide
on this form will be used to calculate your round trip expenses between your address and the
appointment location. Information requested on this form is voluntary. However, if you do not
provide the required information, we will be unable reimburse you for your travel related expenses
to and from the consultative examination and or test. While the information you furnish on this form
would almost never be used for any purpose other than calculating and paying you for your travel
expenses, such information may be disclosed by SSA for the following purposes (1) to assist SSA
in determining the right to Social Security benefits for yourself or another person; (2) to facilitate
statistical research and audit activities necessary to assure the integrity and improvement of
programs administered by SSA, and (3) to comply with laws and regulations requiring the exchange
of information between SSA and another agency.
Explanations about these and other reasons why information about you 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.
See Revised Paperwork
PAPERWORK REDUCTION ACT Reduction Act
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. You may
send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 212356401. Send only comments relating to our time estimate to this address, not the completed
form.

Form SSA-104 (12-2007)

2

Privacy Act Statement
Collection and Use of Personal Information
Sections 404.999a, 404.999b, 404.999c, and 404.999d of the Social Security Act, as amended,
authorize us to collect this information. The information you provide will be used to calculate
your round trip expenses between your address and the appointment location.
The information you furnish on this form is voluntary. However, failure to provide the requested
information may prevent us from reimbursing you for your travel related expenses to and from
the consultative examination and test.
We rarely use the information you supply for any purpose other than for calculating your travel
expenses between your address and the appointment location. However, we may use it for the
administration and integrity of Social Security programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit or investigative activities necessary to assure
the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local government
agencies. Information from these matching programs can be used to establish or verify a person’s
eligibility for Federally funded or administered benefit programs and for repayment of payments
or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and
systems is available on-line at www.socialsecurity.gov or at your local Social Security office.

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Sections 404.999a, 404.999b, 404.999c, and 404.999d of the Social Security Act, as amended,
authorize us to collect this information. The information you provide will be used to calculate
your round trip expenses between your address and the appointment location.
The information you furnish on this form is voluntary. However, failure to provide the requested
information may prevent us from reimbursing you for your travel related expenses to and from
the consultative examination and test.
We rarely use the information you supply for any purpose other than for calculating your travel
expenses between your address and the appointment location. However, we may use it for the
administration and integrity of Social Security programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department of
Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit or investigative activities necessary to assure
the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local government
agencies. Information from these matching programs can be used to establish or verify a person’s
eligibility for Federally funded or administered benefit programs and for repayment of payments
or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and
systems is available on-line at www.socialsecurity.gov or at your local Social Security office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.