Form SSA-2935 Authorization to the Social Security Administration to O

Form Approved
OMB No. 0960-XXXX

Social Security Administration

AUTHORIZATION TO THE SOCIAL SECURITY ADMINISTRATION
TO OBTAIN PERSONAL INFORMATION
BENEFICIARY’S NAME

SOCIAL SECURITY NUMBER

STREET ADDRESS

CITY

STATE

ZIP CODE

I authorize the Individual, Organization or Agency listed below to disclose to the Social
Security Administration information about me relating to a claim for Social Security
benefits. I understand that this information will be kept confidential as required by the
Social Security Act and the Privacy Act of 1974. This authorization shall remain in
effect for no longer than 12 months from the date of my signature.
Name of Individual, Organization, or Agency
Address

City

Signature of
(Write in ink)

State

Beneficiary (First name, middle initial, last name)

Zip
Code

Date (Month,day, year)

SIGN
HERE
Signature of Representative Payee or guardian (First name, middle initial, last name)
(Write in ink)

Date (Month, day, year)

SIGN
HERE
Witnesses are required ONLY if this authorization has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who knows the applicant must sign below, giving their full addresses.
Signature of Witness
(Write in ink)

(First name, middle initial, last name)

Date (Month, day, year)

(First name, middle initial, last name)

Date (Month, day, year)

SIGN HERE
ADDRESS
Signature of Witness
(Write in ink)

SIGN HERE
ADDRESS
Form SSA-2935-U3 (XX/2008)

Privacy Act Statement
The information requested on this form is authorized under Section 205 of the Social Security Act. While
the information you furnish on this form would almost never be used for any purpose other than the
intended use of this form, such information may be disclosed by the Social Security Administration (SSA)
as generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act of 1974, as amended. This includes
using the information as necessary for administrative purposes or as authorized by routine uses in the
applicable Privacy Act system of records. For example, SSA may disclose information to other agencies,
such as the General Services Administration and the National Archives Records Administration, to comply
with Federal laws requiring the release of information from our records. SSA may also use the information
you give us when we match records with those of other Federal, State or local government agencies. The
law allows SSA to do this even if you do not agree to it. Explanations about possible reasons why
information you provide us may be used or provided to other agencies are available upon request from
any Social Security office.

Form SSA-2935-U3 (XX/2008)