Submit the completed form to the Social Security Administration as instructed. This may include mailing the form to your local SSA office, faxing it to the designated number, or submitting it online through the SSA's website or online submission forms. Always ensure you have a copy of the completed form for your records. For specific submission instructions, contact your local SSA office or visit the SSA website for guidance.

Important dates for this form include submission deadlines for benefit applications and responses to SSA requests. Specific dates will vary based on individual circumstances and SSA notifications. Always check with the SSA for the most accurate and relevant deadlines.

The purpose of this form is to authorize the Social Security Administration (SSA) to obtain personal information from public and private records custodians. This information is crucial for determining eligibility for various benefits and programs administered by the SSA. By completing this form, individuals ensure that the SSA has access to the necessary records to make informed decisions regarding their benefit applications. This form also serves to protect the privacy and rights of individuals by ensuring that their personal information is disclosed only for the specified purposes authorized. The SSA utilizes this form to gather essential data, verify eligibility, and process benefit claims efficiently. Furthermore, the form provides transparency and accountability by outlining the circumstances under which the information may be used or shared, as detailed in the privacy notice. This helps individuals understand how their information will be handled and the steps taken to safeguard their privacy.

• 1. Authorizing Person: The name of the individual about whom the information is being requested.
• 2. Social Security Number: The Social Security Number of the Authorizing Person.
• 3. Claimant/Beneficiary: If applicable, the name of the Claimant or Beneficiary, if different from the Authorizing Person.
• 4. Claimant/Beneficiary's Social Security Number: The Social Security Number of the Claimant or Beneficiary, if applicable.
• 5. Authorizing Person's Signature: The signature of the Authorizing Person authorizing the disclosure of personal information.
• 6. Mailing Address: The mailing address of the Authorizing Person, including City, State, and ZIP Code.
• 7. Signature of Witness: Signatures of two witnesses, along with their full addresses, if the Authorizing Person signs by mark (X).

Failure to submit this form can result in delays or denial of benefit eligibility determinations by the Social Security Administration. It is crucial to complete and submit the form promptly.

• Delayed Benefit Processing: Submitting the form late can delay the processing of your benefit application.
• Denial of Benefits: Failure to provide the required authorization may lead to denial of benefits.

• 1. Benefit Applications: When applying for benefits, including SSI, veterans benefits, or other SSA-administered programs.
• 2. Legal Proceedings: In legal cases related to SSA programs where access to records is necessary.
• 3. Income/Health Program Eligibility: For determining eligibility for state or federal health and income programs.
• 4. Research and Audit: When the information is needed for statistical research or SSA audits.
• 5. Congressional Inquiries: When requested by a congressman or the President's Office to respond to inquiries.