Microsoft Word - SSA-4640_(2018 Update) 2

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Social Security Administration
AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN ACCOUNT
RECORDS FROM A FINANCIAL INSTITUTION AND REQUEST FOR RECORDS (MEDICARE)
CUSTOMER’S NAME

NAME AND ADDRESS OF FINANCIAL INSTITUTION

SOCIAL SECURITY NUMBER

ACCOUNT NUMBER(S) (INDIVIDUAL OR JOINT)

,

,

A request for records will be made by the Social Security Administration to determine initial or continuing eligibility and the accuracy of
the subsidy amount for Medicare Part D-Extra Help with Medicare Prescription Drug Costs:
1. This authorization is valid for up to 3 months from the date of my signature; and
2. I have the right to revoke this authorization at any time before any records are disclosed; and
3. The Social Security Administration is requesting all records appearing on the back of this authorization, whether or not listed
above; and
4. 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
5. This authorization is not required as a condition of doing business with the financial institution named above; and
6.

As a customer, my authorization is voluntary; however, failure to provide my signature below may result in a suspension or
loss of eligibility.

I authorize any custodian of records at the financial institution named above to disclose to the Social Security Administration any
records about my financial business or that of the person named above whom I legally represent or whose benefit I manage.
CUSTOMER’S SIGNATURE

MAILING ADDRESS

DATE

LEGAL REPRESENTATIVE’S OR REPRESENTIVE PAYEE’S
SIGNATURE

REPRESENTATIVE’S MAILING ADDRESS

DATE

Your authorization does not ordinarily have to be witnessed. However, if you have signed by mark (X), two witnesses to the signing
who know you must sign below giving their full addresses.
1. SIGNATURE OF WITNESS
2. SIGNATURE OF WITNESS

ADDRESS (Number, Street, City, State, Zip Code)

ADDRESS (Number, Street, City, State, Zip Code)

I CERTIFY that the applicable provisions of the Right to Financial Privacy Act of 1978 (12U.S.C. 3401-3422) have been complied within
this request. Pursuant to the Right to Financial Privacy Act of 1978, good faith reliance upon this certification relieves your institution
and its employees and agents of any possible liability to the customer in connection with the disclosure of these financial records.
TELEPHONE NUMBER (INCLUDE AREA CODE)
DATE
SIGNATURE OF SOCIAL SECURITY ADMINISTRATION
REPRESENTATIVE

ADDRESS

Form SSA-4640

1

REQUEST FOR RECORDS
The customer's authorization for release of the information contained in your records appears on the front of this form.

INSTRUCTIONS FOR COMPLETION
•
•

•
•

Refer to the front of this form for information concerning the accounts to be verified.
Spaces are available for up to four accounts. If there are more than four accounts, please provide information on a
separate sheet of paper. Note: copies of bank records, including computer printouts are acceptable in lieu of
manual entries on the form.
IN ALL CASES, A FINANCIAL INSTITUTION REPRESENTATIVE’S SIGNATURE MUST APPEAR IN THE SPACE
PROVIDED AT THE END OF THIS FORM. A postage free return envelope is enclosed for your convenience.
If no accounts are located, check box below and sign where indicated.
ACCOUNT 1

ACCOUNT 2

ACCOUNT 3

ACCOUNT 4

TYPE OF
ACCOUNT1
ACCOUNT
NUMBER
NAME(S) ON
AND EXACT
ACCOUNT
DESIGNATION
BALANCE AS
OF
(Date)
BALANCE AS
OF
(Date)

1 Checking, Savings, Time or Certificate of Deposit, Keogh, IRA, Trust, Mutual Funds, Stocks, Bonds, Christmas or Vacation Club, etc.

□ No accounts were located for this customer.
I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge.
Signature of Financial Institution Representative

Phone Number
(

)

Date

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 a maximum of 1 minute for Medicare Part D subsidy applicants
and 4 minutes for financial institutions to read the instructions, gather the facts, and answer the questions. 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.

Form SSA-4640

2

See Revised Privacy Act &
PRA Statements attached
Privacy Act Statement
Collection and Use of Personal Information

Section 1860D-14(a)(3) of the Social Security Act, as amended, allows us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may affect our ability to determine your eligibility for the Medicare Part D
subsidy.
We will use the information to obtain financial information to determine eligibility, and the
accuracy of the subsidy amount for Medicare Part D benefits. We may also share your
information for the following purposes, called routine uses:


To applicants, claimants, prospective applicants or claimants (other than the data subjects
and their authorized representatives) to the extent necessary for the purpose of pursuing
Medicare Part D and Part D subsidy entitlement or appeal rights; and



To the Centers of Medicare and Medicaid Services, for the purpose of administering
Medicare Part D enrollment and premium collection.

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 Notice
(SORN) 60-0321, entitled Medicare Database File, as published in the Federal Register (FR) on
July 25, 2006, at 71 FR 42159. Additional information and a full listing of all our SORNs are
available on our website at www.ssa.gov/privacy.

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Section 1860D-14(a)(3) of the Social Security Act, as amended, allows us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent an accurate and timely decision on Medicare Part D benefits
eligibility or continuing eligibility.
We will use the information you provide to obtain account records from a financial institution to
review the accuracy of the eligibility and subsidy amount of Medicare Part D benefits. We may
also share the information for the following purposes, called routine uses:
•

To applicants, claimants, prospective applicants or claimants (other than the data
subjects and their authorized representatives) to the extent necessary for the purpose
of pursuing Medicare Part D and Part D subsidy entitlement or appeal rights; and

•

To the Centers of Medicare and Medicaid Services (CMS), for the purpose of
administering Medicare Part D enrollment and premium collection and Medicare
Advantage Part C premium collections, as well as, Medicare Part B income-related
monthly adjustment amounts.

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 Notice
(SORN) 60-0321, entitled Medicare Database (MDB) File, as published in the Federal Register
(FR) on July 25, 2006, at 71 FR 42159. Additional information, and a full listing of all of our
SORNs, is available on our website at http://www.ssa.gov/privacy.

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 1 minute for Medicare Part D
subsidy applicants and 4 minutes for financial institutions 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.