Form SSA-4641-U2 Authorization for the Social Security Administration to

Form Approved
OMB No. 0960-0293

Social Security Administration

AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN ACCOUNT
RECORDS FROM A FINANCIAL INSTITUTION AND REQUEST FOR RECORDS
CUSTOMER'S NAME

SOCIAL SECURITY NUMBER

NAME AND ADDRESS OF FINANCIAL INSTITUTION

APPLICANT/RECIPIENT IF OTHER THAN CUSTOMER

ACCOUNT NUMBER(S)
JOINT ACCOUNT,

DIRECT DEPOSIT

JOINT ACCOUNT,

DIRECT DEPOSIT

,

JOINT ACCOUNT,

DIRECT DEPOSIT

,

The Social Security Administration will request records to determine initial or continuing eligibility and the accuracy of the payment for
Supplemental Security Income benefits. I understand that any information obtained will be kept confidential and that:
1. I have the right to revoke this authorization at any time before any records are disclosed; and
2. If I am an applicant or recipient, failing to provide or revoking my authorization will result in a denial or suspension of benefits; and
3. If I am a person whose income and resources the Social Security Administration considers as being available to an applicant or
recipient, failing to provide or revoking my authorization may result in a denial of benefits for the applicant or a suspension of
benefits for the recipient; and
4. The Social Security Administration may request all records about me from any financial institution, whether or not listed above; and
5. 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
6. This authorization is not required as a condition of doing business with the financial institution named above.
I authorize any custodian of records at this financial institution 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 benefits I manage.
CUSTOMER'S SIGNATURE/AUTHORIZATION

MAILING ADDRESS

DATE

LEGAL REPRESENTATIVE'S SIGNATURE /AUTHORIZATION

LEGAL 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 with in
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.
AUTHORIZATION OF SOCIAL SECURITY ADMINISTRATION
REPRESENTATIVE

TELEPHONE NO (INCLUDE AREA CODE)

ADDRESS

Form SSA-4641-U2 (01-2009) EF (01-2009)

(1)

DATE

Customer's Name:

Social Security Number:

REQUEST FOR RECORDS
This request is authorized by section 1631(e)(1)(B) 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 above for Supplemental
Security Income benefits. The customer's authorization for release of the information contained in your records appears
on page one of this form.
Please provide information for the period ______________ through _____________ for the account number(s) listed above
and any others held (either individually or jointly) by the above named customer.
SSA REMARKS

FOR COMPLETION BY THE FINANCIAL INSTITUTION REPRESENTATIVE
INSTRUCTIONS FOR COMPLETION
Refer to page one for information concerning the accounts to be verified. If the customer owns other accounts
that are not listed, please provide information on those accounts for the time frame requested.
We need account information even if the account has been closed or the account number has changed.
Spaces are available for up to three accounts. If there are more than three accounts, please provide
information on a separate sheet of paper.
Please include at the end of this form the name of the financial institution representative providing account
information.
Please return this form and all supporting materials to the Social Security Administration in the
postage free return envelope provided.
If no accounts are located, check the box below where indicated.
ACCOUNT 1
TYPE OF
ACCOUNT

ACCOUNT 2

ACCOUNT 3

1

ACCOUNT
NUMBER
NAME(S) ON
AND EXACT
ACCOUNT
DESIGNATION
1 Checking, Savings, Time/Certificate of Deposit, Keogh, IRA, UGMA/UTMA, Escrow, Etc.

No accounts were located for this customer.
Copies of account records may be submitted in lieu of entering data below.
For all accounts, provide opening balances as of the first day of the month for each account, for each month
listed in the period.
Unless this box is checked, do not provide interest paid or credited during each month.
Form SSA-4641-U2 (01-2009) EF(01-2009)

(2)

Customer's Name:

Social Security Number:

ACCOUNT 1
Month/Year

Balance

ACCOUNT 2
Interest
Paid

Balance

ACCOUNT 3
Interest
Paid

Phone Number
(
)

Name of Financial Institution Representative

Date

REMARKS

Form SSA-4641-U2 (01-2009 ) EF(01-2009)

Balance

(3)

Interest Paid

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 about 6 minutes to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory
or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). 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.
See revised PRA and PA Statements Attached

Form SSA-4641-U2 (01-2009) EF (01-2009)

(4)

SSA will insert the following revised PRA and Privacy Act Statements into the
form at its next scheduled reprint:
PRIVACY ACT STATEMENT
Collection and Use of Information
Section 1631(e)(1)(B) of the Social Security Act, as amended, authorizes us to collect this
information. We will use this information to determine initial or continuing Supplemental
Security Income benefits.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may prevent an accurate and timely decision on eligibility, denial or
suspension of benefits.
We rarely use the information for any purpose other than for determining Supplemental Security
Income eligibility. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose the 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 us in establishing rights to Social Security
benefits and coverage;
2. To comply with Federal laws requiring the release of information from our 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, (check statue)
4. To facilitate statistical research, audit, and investigatory activities necessary to assure the
integrity and improvement of Social Security 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 and administered benefit programs and for repayment of
payment’s or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act Systems of
Records Notices entitled, Claims Folders Systems, 60-0089, and Supplemental Security income
Record and Special Veterans Benefits, 60-0103. This notice, additional information regarding
our programs and systems are available on-line at www.socialsecurity.gov or at your local Social
Security office.