Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - SSA-4641-U2

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 204(b), 1631(b)(1)(B), and 1631(e)(1)(B) of the Social Security Act, as amended, allow
us to collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent us from making an accurate and timely
decision on benefit eligibility or from waiving an overpayment.
We will use the information to verify eligibility for benefits or to assist us in waiving a Social
Security overpayment. We may also share your information for the following purposes, called
routine uses:


Disclosure to contractors and other Federal agencies, as necessary, for the purpose of
assisting the Social Security Administration (SSA) in the efficient administration of its
programs; and



To student volunteers and other workers, who technically do not have the status of
Federal employees, when they are performing work for SSA.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0094, entitled Recovery of Overpayments Accounting and Reporting/Debt
Management System, as published in the Federal Register (FR) on August 23, 2005, at 70 FR
49354 and 60-0103, entitled Supplemental Security Income Record and Special Veterans
Benefits, as published in the FR on January 1, 2006, at 71 FR 1830. Additional information, and
a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.

Form SSA-4641-U2