Form SSA-4640 Authorization...

Form Approved
OMB No. 0960-0729

Social Security Administration

AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN ACCOUNT
RECORDS FROM A FINANCIAL INSTITUTION AND REQUEST FOR RECORDS (MEDICARE)
NAME AND ADDRESS OF FINANCIAL INSTITUTION

CUSTOMER’S NAME

SOCIAL SECURITY NUMBER

ACCOUNT 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 the
subsidy amount for Medicare Part D-Extra Help with Medicare Prescription Drug Costs:
1.
2.
3.

This authorization is valid for up to 3 months from the date of my signature; and
I have the right to revoke this authorization at any time before any records are disclosed; and
The Social Security Administration is requesting all records appearing on the back of this authorization, whether or not listed
above; and
4. I have the right to obtain a copy of the record which the financial institution keeps concerning the instances when it has disclosed
records to a Government authority unless the records were disclosed because of a court order; and
5. This authorization is not required as a condition of doing business with the financial institution named above; and
6. As a customer, my authorization is voluntary; however, failure to provide my signature below may result in a suspension or loss
of eligibility.
I 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 manage.
CUSTOMER’S SIGNATURE
MAILING ADDRESS
DATE

LEGAL REPRESENTATIVE’S OR REPRESENTIVE PAYEE’S SIGNATURE

REPRESENTATIVE’S MAILING ADDRESS

DATE

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
2. SIGNATURE OF WITNESS

ADDRESS (Number,

Street, City, State, Zip Code)

ADDRESS (Number,

Street, City, State, Zip Code)

I CERTIFY that the applicable provisions of the Right to Financial Privacy Act of 1978 (12U.S.C. 3401-3422) have been complied within
this request. Pursuant to the Right to Financial Privacy Act of 1978, good faith reliance upon this certification relieves your institution and
its employees and agents of any possible liability to the customer in connection with the disclosure of these financial records.
SIGNATURE OF SOCIAL SECURITY ADMINISTRATION
TELEPHONE NO (INCLUDE AREA CODE)
DATE
REPRESENTATIVE

ADDRESS

____________________________________________________________________________________________________________________________
1
Form SSA-4640

REQUEST FOR RECORDS
This request is authorized by section 1860D-14 of the Social Security Act, as amended. While you are not required to
respond, your cooperation will help us determine the eligibility of the applicant or recipient named below for the Medicare
Part D Extra Help With Medicare Prescription Drug Costs. The customer's authorization for release of the information
contained in your records appears on the front of this form.






INSTRUCTIONS FOR COMPLETION
Refer to the front of this form for information concerning the accounts to be verified.
Spaces are available for up to four accounts. If there are more than four accounts, please provide information on a
separate sheet of paper. Note: copies of bank records, including computer printouts are acceptable in lieu of
manual entries on the form.
IN ALL CASES, A FINANCIAL INSTITUTION REPRESENTATIVE’S SIGNATURE MUST APPEAR IN THE SPACE
PROVIDED AT THE END OF THIS FORM. A postage free return envelope is enclosed for your convenience.
If no accounts are located, check box below and sign where indicated.
ACCOUNT 1

ACCOUNT 2

ACCOUNT 3

ACCOUNT 4

TYPE OF
1
ACCOUNT
ACCOUNT
NUMBER
NAME(S) ON
AND EXACT
ACCOUNT
DESIGNATION
BALANCE AS
OF
(Date)
BALANCE AS
OF
(Date)
1

Checking, Savings, Time or Certificate of Deposit, Keogh, IRA, Trust, Mutual Funds, Stocks, Bonds, Christmas or Vacation Club, etc.



No accounts were located for this customer.
I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge.
Signature of Financial Institution Representative

Phone Number
(
)
Date

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 a maximum of 1 minute for Medicare Part D subsidy applicants and 4 minutes for
financial institutions to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate
above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address,
not the completed form.
We may also use the information you give us when we match records by computer. Matching programs compare our records with those
of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies
for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security
offices. If you want to learn more about this, contact any Social Security office.

Please see below for revised Privacy Act
and Paperwork Reduction Act Statements
____________________________________________________________________________________________________________________________
2
Form SSA-4640

Privacy Act Statement
Collection and Use of Personal Information
Section 1860D-14 of the Social Security Act, as amended, authorizes us to collect this
information. The information you provide will be used to obtain financial information in
regards to determining initial or continuing eligibility, as well as the accuracy of the
subsidy amount for Medicare Part D benefits.
The information you furnish on this form is voluntary. However, failure to provide the
requested information could result in a suspension or loss of eligibility.
We rarely use the information you supply for any purpose other than for determining
eligibility for Medicare Part D. 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 Medicare 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 of Medicare 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.
Explanations about these and other reasons why information you provide us may be used
or given out are available in Systems of Records Notice 60-0321 (Medicare Database
File). The Notice, additional information about this form, and any other information
regarding our systems and programs, are available on-line at www.ssa.gov or at your
local Social Security office.

The following revised PRA Statement will be inserted into
the form at its next scheduled reprinting:
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 a maximum of
1 minute for Medicare Part D subsidy applicants and 4 minutes for financial institutions
to read the instructions, gather the facts, and answer the questions. Send only comments
relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 212356401.