Form SSA-8240 (09-2017)
Discontinue Prior Editions
Social Security Administration
Page 1 of 3
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:
• Section 1184 of the Social Security Act (Act) authorizes the Social Security Administration (SSA) to enter into information
exchanges with payroll data providers. SSA will use my authorization to obtain wage and employment information from
payroll data providers. Section 1184(c)(1) of the Act defines a payroll data provider as payroll providers, wage verification
companies, and other entities that collect and maintain data about employment and wages.
• 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 we paid you too much in benefits because the payroll data provider reported your wage and employment information
inaccurately, you may have to pay us 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. 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.
SSDI
Yes
No
