Form SSA-9308 Request for Release of Information

1

Social Security Administration

Office of Quality Assurance and

Performance Assessment

(Address of Office)

                                                                                                                   

Date:

Beneficiary:

SSN:

(Address)

The Social Security Administration is conducting a quality review on this account. The following information is needed for our review for the above named individual. We have included a signed authorization for release of the information and a self-addressed stamped envelope for your convenience.

(fill-in)

We appreciate your assistance with our review. If you have any questions, you may phone me at my office between 8:00 a.m. and 4:00 p.m., Monday through Friday. My toll-free telephone number is 1-800- _____.

                                                                                       Sincerely,

                                                                                      

                                                                                       Social Insurance Specialist

Enclosures: Postage-paid envelope

Signed Authorization for Release of Information

PAPERWORK REDUCTION ACT NOTICE

Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C section 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. The OMB Number for this collection is 0960‑0707. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. Send only comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-0001.

Request for Information

SSA-9308