SSA-8240 - Current

Form SSA-8240 (03-2024)
Use (02-2021) until Stock is Exhausted
Social Security Administration

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OMB No. 0960-0807

Authorization for the Social Security Administration
to Obtain Wage and Employment Information
from Payroll Data Providers
1. Individual Whose Wage and Employment Information Will Be Obtained

2. Social Security Number (for Individual)

3. Claimant/Beneficiary (if different from above)

4. Claimant/Beneficiary Social Security
Number (if different from above)

5.

I understand:
• The Social Security Administration (SSA) will use my authorization to obtain wage and employment information from
payroll data providers. Payroll data providers are payroll providers, wage verification companies, and other entities that
collect and maintain data about employment wages. SSA may obtain such wage and employment information through
automated (authorized by Section 1184 of the Social Security Act) or non-automated information exchanges.
• If SSA obtains payroll data provider records about me based on this authorization, it may use the records for purposes
other than for the program that the authorization covers. For example, SSA may use my records to decide whether I can
get benefits under both the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI)
programs, even if this authorization is limited to one program. Additional information about how SSA may use and
disclose my records is in the Privacy Act Statement below.
• SSA will request authorization under the SSDI and SSI programs. SSA will request authorization once under each
program, even if I have multiple SSDI or SSI claims. However, SSA may use my authorization to obtain payroll data
provider records about me for any claims associated with the ones I file, such as a claim for benefits by my spouse or
child. If I revoke my authorization, SSA will not use the authorization to obtain my information for any of my claims under
both programs.
• By authorizing the SSA to obtain my wage and employment information, I will receive protection from certain penalties,
pursuant to section 1129A and section 1631(e)(2) of the Act. I further understand that if I later revoke my authorization, I
will no longer get this protection.
• Not all employers report wage and employment information to payroll data providers that SSA uses. If my employer does
report, SSA will request my wage and employment information from the payroll data provider. I am still responsible for
making sure that my wage and employment information are reported accurately to SSA.
• If SSA paid me too much in benefits because the payroll data provider reported my wage and employment information
inaccurately, I may have to pay SSA back.
• If my employer does not report or stops reporting to a payroll data provider that SSA uses, I will have to report my wage
and employment information.
• I am authorizing payroll data providers (as defined in section 1184 of the Act) to disclose to the SSA data about me or
that of the person named above whom I legally represent.

5.a. Answer questions (5.b. and 5.c.) below by checking Yes or No.
Note: If you are filing or receiving benefits under SSDI and SSI, you must answer both questions.
5.b. Do you give us authorization to obtain your wage and employment information from payroll
data providers for the Social Security Disability Insurance (SSDI) program?
Your authorization will help us determine whether you are entitled to benefits, or continue to be
entitled to benefits. Giving us your authorization may also help us avoid paying the wrong amount.
We will ask for all of your records held by the payroll data provider whenever we determine that we
need these records to make decisions on your entitlement to benefits.

SSDI

Yes

No
Your authorization will remain in effect until:
• We make a final adverse decision on your application for benefits and no other claims or appeals
are pending;
• Your entitlement to benefits ends and no other claims or appeals are pending; or
• You revoke your authorization in writing.

Form SSA-8240 (03-2024)

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5.c. Do you give us authorization to obtain your wage and employment information from payroll
data providers for the Supplemental Security Income (SSI) program?

SSI

Your authorization will help us determine whether you or the person who filed an application for
benefits, is eligible for SSI, or continues to be eligible for SSI. Giving us your authorization may also
help us avoid paying the wrong amount. We will request your records held by the payroll data provider
whenever we determine that we need these records to make decisions on your eligibility for SSI.

Yes

No
Your authorization will remain effective until:
• We make a final adverse decision on the application for benefits and no other claims or appeals
are pending;
• You or the other person's eligibility for payments ends and no other claims or appeals are pending;
• You revoke your authorization in writing; or
• We no longer count your income and resources to the other person.
6.

PLEASE SIGN IN BLACK OR BLUE INK ONLY
Signature

Date signed

If not signed by the individual whose wage and employment information will be obtained, what is the basis for the
authority to sign
Parent of minor

Guardian

Print name of parent/guardian
Mailing address of individual authorizing disclosure

City
7.

State

ZIP Code

Your authorization does not ordinarily have to be witnessed. However, if you have signed using a mark, two witnesses to the
signing who know you must sign below giving their full addresses.
If needed, WITNESS I know the person signing this form or am satisfied of this person's identity:

Mailing Address for Witness 1

If needed, second witness sign here (e.g., if signed with a mark above)

Mailing Address for Witness 2

Form SSA-8240 (03-2024)

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Privacy Act Statement
Collection and Use of Information on your Authorization Form
Sections 205(a), 225(c), and 1631(e) of the Social Security Act, as amended, allow us to collect your
information or the information you are submitting on behalf of another, which we will use to obtain wage and
employment information from payroll data providers and to administer the Social Security Act. Providing the
information is voluntary, but not providing all or part of the information may prevent an accurate and timely
decision regarding Social Security benefits and payments. As law permits, we may use and share the
information you submit, including with employers, contractors, other Federal agencies, and others, as
outlined in the routine uses within System of Records Notice (SORN) 60-0089, available at
www.ssa.gov/privacy. The information you submit may also be used in computer matching programs to
establish or verify eligibility for Federal benefit programs and to recoup debts under these programs.

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. We estimate that it will take about 6 minutes to
read the instructions, gather the facts, and answer the questions. Send only comments regarding this
burden estimate or any other aspect of this collection, including suggestions for reducing this
burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.