Authorization to the Social Security Administration to Obtain Personal Information

SOCIAL SECURITY ADMINISTRATION
Office of Quality Performance

Date:
Applicant Name:
SSN:

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.

We have also included a signed authorization for release of the information and a selfaddressed 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

Sincerely,

Social Insurance Specialist

Enclosures: Postage-paid envelope
Signed Authorization for Release of Information

Form SSA-L2937 (08-2011)

PAPER REDUCTION ACT NOTICE
See Revised PRA and New Privacy Act Statements Attached
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.

Form SSA-L2937 (08-2011)

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

Sections 205(a), 1631(d)(1), and 1631(e)(1)(B) of the Social Security Act, as amended, authorize
us to collect this information. We will use the information you provide to determine eligibility
for our programs.
Furnishing us this information is voluntary. However, failure to provide all or part of the
information could prevent us from making an accurate and timely decision on your continuing
eligibility to our programs.
We rarely use the information you supply for any purpose other than for making a determination
relating to our 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 (e.g., to the Bureau of the
Census and private concerns under contract to Social Security).
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.
A complete list of routine uses for this information are available in Systems of Records Notices
entitled, Quality Review System, 60-0040, and Quality Review Case Files, 60-0042. These
notices, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local 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
(OMB) control number. The OMB control number for this collection is 0960-0066. We
estimate that it will take between 5 minutes to read the instructions, gather the facts, and answer
the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security
Blvd, Baltimore, MD 21235-6401.