SSA-4641 - Contractor Offset for first page (as mentioned in Addendum)

Form Approved
OMB No. 0960-0293

Social Security Administration

AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN ACCOUNT
RECORDS FROM A FINANCIAL INSTITUTION AND REQUEST FOR RECORDS
CUSTOMER'S NAME

SOCIAL SECURITY NUMBER

NAME AND ADDRESS OF FINANCIAL INSTITUTION

APPLICANT/RECIPIENT IF OTHER THAN CUSTOMER

ACCOUNT NUMBER(S)
JOINT ACCOUNT,

DIRECT DEPOSIT

JOINT ACCOUNT,

,

DIRECT DEPOSIT

JOINT ACCOUNT,

DIRECT DEPOSIT

,

I understand:
I have the right to revoke this authorization at any time before any records are disclosed;
The Social Security Administration may request all records about me from any financial institution;
Any information obtained will be kept confidential;
I have the right to obtain a copy of the record which the financial institution keeps concerning the instances
when it has disclosed records to a government authority unless the records were disclosed because of a
court order; and
This authorization is not required as a condition of doing business with any financial institution
The checkbox below shows the reason you are giving us your authorization to contact financial institutions:
Supplemental Security Income Eligibility
The Social Security Administration will request records to determine initial or continuing eligibility and the
accuracy of the payment for Supplemental Security Income (SSI) benefits.
If I am an applicant or recipient, failing to provide or revoking my authorization will result in a denial or
suspension of SSI benefits.
If I am a person whose income and resouorces the Social Security Administration considers as being
available to an applicant or recipient, failing to provide or revoking my authorization may result in a denial
of benefits for the applicant or a suspension of benefits for the recipient.
This authorization is in effect until the earliest of: 1) a final adverse decision on my application for
benefits, 2) the cessation of my eligibility for benefits, or 3) my revocation of this authorization in a
written notification to the Social Security Administration.
Waiver Determination
The Social Security Administration will request records to determine the ability to repay an overpayment in
conjunction with a waiver determination.
Failing to provide or revoking my authorization may result in the Social Secority Administration determining,
on that basis, that adjustment of recovery of the overpayment will not deprove me of funds to pay my bills
for food, clothing, housing, medical care, or other necessary expenses.
This authorization is in effect until the earliest of: 1) a final decision on whether adjustment or recovery of
my overpayment would deprive me of funds to pay my bills for food, clothing, housing, medical care, or
other necessary expenses; or 2) my revocation of this authorization in a written notification to the Social
Security Administration.

Form SSA-4641 (01-2016) UF (01-2016)
Destroy Prior Editions

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