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

Form Approved
OMB No. 0960-0189

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: _____________________________

State: ___________________________

Signature of Beneficiary (First name, middle initial, last name)
(Write in ink)

Zip Code: __________________

Date (Month, day, year)

SIGN
HERE

Signature of Representative Payee or Guardian (First name, middle initial, last name) Date (Month, day, year)
(Write in ink)
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 know 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 (06-2008) ef (6-2008)

Privacy Act StatementSee Revised 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.

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 OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is
listed under U. S. Government agencies in your telephone directory or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address,
not the completed form.

SSA-2935-U3 (06-2008) ef (6-2008)

SSA will insert the following revised PRA Statement into the form at its next scheduled
reprinting:
Privacy Act Statement

Collection and Use of Personal Information

Section 205 of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide on this form to obtain information
from another individual, organization, or agency regarding your Social Security benefits.
Completion of this form is voluntary; however, failure to provide all or part of the
information could prevent us from correctly reviewing your Social Security benefits.
We rarely use this information you supply for any purpose other than for reviewing your
claim for Social Security benefits. 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 and improvement 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.