Fillable Authorization For The Social Security Administration To Obtain Personal Information

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Authorization For The Social Security Administration To Obtain Personal Information

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Form SSA-8510 (06-2017) UF
Social Security Administration
AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION
TO OBTAIN PERSONAL INFORMATION
Form Approved
OMB No. 0960-0801
Authorizing Person (Person about whom information is being requested) Social Security Number
Claimant/Beneficiary (If other than authorizing person) Claimant's/Beneficiary's Social Security Number
I authorize any public or private custodian of records to disclose to the Social Security Administration any records or information
about me. In the case of a minor or incapable person, I, as guardian or representative, authorize the same disclosure of records
about the person I represent.
Authorizing Person's Signature Date
Mailing Address City and State ZIP Code
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
Address (Number, Street, City, State, ZIP Code)
2. Signature of Witness
Address (Number, Street, City, State, ZIP Code)
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 1631(e) of the Social Security Act, as amended, authorize us to collect this information. We will use the
information you provide on this form to obtain information about you from any public or private custodian regarding your eligibility
for Social Security benefits.
You do not have to provide us this information. Your responses are voluntary. However, failure to provide all or part of the
information could prevent us from making an accurate and timely decision regarding your Social Security benefits.
We rarely use this information you supply for any purpose other than for reviewing your claim for Social Security 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.
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 our System of Records Notices entitled, Claims Folders
Systems (60-0089) and the Master Beneficiary Record (60-0090). These notices, additional information regarding this form,
routine uses of information, and 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 control number. We estimate that it will take about 5 minutes to read the instructions, gather the facts,
and answer the questions. Send only comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD
21235-6401.
Form SSA-8510 (06-2017) UF
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Authorization For The Social Security Administration To Obtain Personal Information

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Completed 27 July 2020

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