Authorization to the Social Security Administration to Obtain Personal Information

1

Social Security Administration

Office of Quality Performance

(Address of Office)

                                                                                                                   

Date:

Applicant:

SSN:

(Address)

The Social Security Administration is conducting a quality review on this account. The following information is needed for our review for the above named applicant.

(fill-in)

We have also included a signed authorization for release of the information and a self-addressed stamped envelope for your convenience.

We appreciate your assistance with our review. If you have any questions, you may phone me at my office between 8:00 a.m. and 4:00 p.m., Monday through Friday. My toll-free telephone number is 1-800- _____.

                                                                     Sincerely,

                                                                                      

                                                                     Social Insurance Specialist

Enclosures: Postage-paid envelope

Signed Authorization for Release of Information

PAPER REDUCTION ACT NOTICE

Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C section 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. The OMB number for this collection is 0960-0066. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. Send only comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-0001.

Request for Information

SSA-9308 (4-2007)