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

SSA collects and verifies financial account information from individuals requesting a waiver of their Title II and Title XVI overpayments, as well as those who apply for, or currently receive (in the case of redetermination) Supplemental Security Income (SSI) payments. We require financial information from these individual’s to: (1) determine the eligibility of the applicant or recipient for SSI benefits; or (2) determine if a request to waive a Social Security overpayment defeats the purpose of the Act. If an individual provides incomplete or seemingly altered records, or if records are unavailable, SSA contacts his or her financial institutions to verify the existence; ownership; and value of accounts owned. Financial institutions need individuals to sign Form SSA-4641-F4, or contact SSA and use the Internet version, e4641, to authorize them to disclose the individual’s records to SSA. The respondents are Title II and Title XVI recipients applying for waivers, or SSI applicants, recipients, and their deemors to determine SSI eligibility. We are submitting a non-substantive Change Request to request to add a new modality of completion for the SSA-4641. The new version will be published as an overprint (SSA-4641 OP1) and will not replace any existing modalities, we are updating disclosures and the Privacy Act Statement and we are moving the financial account identification from the authorization portion of the form to a new Part Two of the form and broken up the various parts of this multipurpose form into four sections.

The latest form for Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records expires 2027-11-30 and is listed under ICR 202604-0960-001.

Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - Individuals (Paper and Electronic)

Federal Enterprise Architecture: Income Security - General Retirement and Disability

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