Form SSA-3194 Renewal Certification

[Type text] [Type text] OMB No. 0960-0624

PERMANENT MEDICAL PARKING RENEWAL CERTIFICATION In Connection With Medical Parking at SSA Headquarters Buildings in Baltimore, MD
To Be Completed Only By Individuals Possessing A Medical Parking Assignment
INSTRUCTIONS: The Social Security Administration (Agency or SSA) offers medical parking as a reasonable accommodation to employees who are “disabled,” as defined by Rehabilitation Act of 1973, as amended, 29 U.S.C. 791, et seq., and the ADA Amendment Act of 2008. Based on your prior application, SSA provided you with a medical parking assignment, which was valid for a one year period. Before the expiration of your current parking permit, please complete the below certification and return it to the Deputy Director, Office of Protective Security Services, P.O. Box 17789, Baltimore, MD 21235-7789, or fax to (410) 597-0455.
1. Name (last, first, middle int.):			2. Last four digits of SSN:
3. Office/Company:			4. Work Schedule:
5. Building/Room No.:	6. Identify Current Parking Space: Area: _______ Lane: _______ Space: _______
Renewal Certification	I hereby certify that the physical or mental impairment for which I received medical parking has not materially improved and that I still need a medical parking assignment. I understand that if the physical or mental impairment for which I received medical parking improves, that I will promptly inform the Deputy Director, Office of Protective Security Services, and that I may no longer be eligible for a medical parking assignment. I further certify that if I leave the employ of the Agency, that I will promptly return this permit to the Division of Security Services.
Signature		Date		Telephone no.
PRIVACY ACT STATEMENT: SSA is authorized to collect the information requested on this form by the Federal Property and Administrative Services Act of 1949, as amended, 63 Statute 377, 390 (40 U.S.C. 471, 486 and 41 CFR 101-20.104-2), and Rehabilitation Act of 1973, as amended, 29 U.S.C. 791, et seq., and the ADA Amendment Act of 2008. Executive Order 9397 (November 22, 1943) authorizes use of the Social Security Number. SSA uses this information to provide standards for apportioning and assignment of handicapped parking spaces on SSA managed, controlled or assigned property, and to allocate and check parking spaces assigned to handicapped personnel and others. SSA also uses it to determine reasonable accommodations. You do not have to give SSA this information. Your submission is voluntary. SSA, however, will use the information provided by you to facilitate the processing of your request. Therefore, the failure to fully complete the form and provide the requested information may make it impossible for SSA to process your request. SSA will not make any disclosure of this information to agencies or individuals outside this department unless the law permits, you provide written consent, or it is otherwise required. For example, SSA may disclose the information to the Department of Justice in the event of litigation where the defendant is SSA, any SSA component, or any SSA employee in his or her official capacity; to a congressional office requesting information on your behalf; and to volunteers or individuals working under a service contract and other individuals performing functions for SSA if they need access to the records for the performance of their assigned agency functions. You may contact the Deputy Director, Office of Protective Security Services at (410) 966-8814 for further explanation as to the reasons why the SSA may use or disclose information about you.
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 five minutes to read the instructions, and answer the questions. You may send comments on our time estimate above to: SSA 1338 Annex Building, Baltimore, MD 21235-0001. Send only comments relating to our time estimate to this address, not the completed form.