AUTHORIZATION FOR THE SOCIAL SECURITY …

Form ApprovedOMB No. 0960-0293 SOCIAL SECURITY ADMINISTRATIONAUTHORIZATION FOR THE SOCIAL SECURITY administration TO OBTAIN ACCOUNT RECORDS FROM A FINANCIAL INSTITUTION AND REQUEST FOR RECORDSCUSTOMER'S NAMESOCIAL SECURITY NUMBERAPPLICANT/RECIPIENT IF OTHER THAN CUSTOMERSOCIAL SECURITY NUMBERNAME AND ADDRESS OF FINANCIAL INSTITUTIONACCOUNT 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 payment for Supplemental SECURITY Income benefits. I understand that any information obtained will be keptconfidential and that:This AUTHORIZATION is valid for up to 3 months from the date of my signature; andI have the right to revoke this AUTHORIZATION at any time before any records are disclosed; andThis AUTHORIZATION is not required as a condition of doing business with the financial institution named above; andI 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 ADDRESSDATEREPRESENTATIVE'S MAILING ADDRESSDATECUSTOMER'S SIGNATURELEGAL REPRESENTATIVE'S OR REPRESENTATIVE PAYEE'S SIGNATUREYour AUTHORIZATION does not ordinarily have to be witness

form approved social security administration omb no. 0960-0293 authorization for the social security administration to obtain account records from a financial institution and request for records

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  Administration, Social, Security, Social security administration, For the social security, For the social security administration to

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