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
HERE
Mailing Address

City and State

ZIP Code

Your 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 FORMPRIVACY 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:

See revised Privacy Act Statement
below.

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.

Form SSA-8510 (9-87)

*U.S. Government Printing Office: 1995- 387-008/20192

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, 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

Privacy Act Statement
Authorization for the Social Security Administration to Obtain Personal Information

Sections 205(a) and 1631(e) of the Social Security Act, as amended, authorize us to collect the
information contained on this form. We will use the information you provide to determine your
eligibility for payments. Your responses are voluntary. However, failure to provide all or part of
the requested information may affect whether benefits are payable to you.
We rarely use the information provided on this form for any other purpose other than the reasons
explained above. 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 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 and investigative activities necessary to ensure the
integrity and improvement of Social Security programs.
A complete list of routine uses for this information is available in Systems of Records Notice,
entitled, Master Beneficiary Record, 60-0090. The notice, additional information regarding this
form, and information regarding our program and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security office.