Get SSA-8510 1987-2024

2. Signature of Witness Address Number Street City State ZIP Code Form SSA-8510 9-87 COLLECTION AND USE OF INFORMATION ON YOUR CONSENT FORM PRIVACY ACT NOTICE The Social Security Administration is authorized to collect the information on your consent form under sections 205 a and 1631 e of the Social Security Act as amended 42 U.S.C. SOCIAL SECURITY ADMINISTRATION AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN PERSONAL INFORMATION Authorizing Person Person about whom information is being requested Social Security Number Claimant/Beneficiary If other than authorizing person 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. Date SIGN HERE City and State ZIP Code Mailing Address 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. 405 and 42 U*S*C. 1383 e. Giving us the information on this form is voluntary. You do not have to do it but benefits may not be payable unless you give us this information* We may routinely give out the information obtained without your consent if 1. We need to get more information to decide eligibility for benefits 2. An agency needs this information to decide eligibility for a health or income program such as Supplemental Security Income SSI State supplementary payments food stamps Medicaid energy assistance Veterans benefits railroad unemployment insurance or Basic Educational Opportunity Grants 3. A Federal law requires that we give out this information 4. Your congressman or the President s Office needs this information to answer questions you ask them 5. Someone needs this information to do statistical research or audit reports for us related to the Social Security programs or 6. The Department of Justice needs the information to represent the Federal Government in a court suit related to an SSA program* These and other reasons why information about you may be used or given out are explained in the Federal Register. If you would like more information about this get in touch with any Social Security office. U*S* Government Printing Office 1998 - 433-335/80148. SOCIAL SECURITY ADMINISTRATION AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN PERSONAL INFORMATION Authorizing Person Person about whom information is being requested Social Security Number Claimant/Beneficiary If other than authorizing person 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. 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. Date SIGN HERE City and State ZIP Code Mailing Address 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. .