Current SSA-3194

Social Security Administration

OMB No. 0960-0624

PERMANENT MEDICAL PARKING
RENEWAL CERTIFICATION

In Connection With Medical Parking at SSA Headquarters Buildings in Baltimore, MD
To Be Completed 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 Amendments 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. If you have any questions, you may contact the Deputy Director,
Office of Protective Security Services at (410) 966-8814.
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:

Renewal
Certification

Lane:

Space:

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:

Form SSA-3194 (03-2012)

Date:

Telephone No.:

Permanent Medical Parking Renewal Certification
in Connection With Medical Parking at SSA headquarters Building in Baltimore, MD
Privacy Act Statement
Collection and Use of Personal Information
The Federal Property and Administrative Services Act of 1949, as amended, 63 Statute 377, 390 (40 U.
S.C. 471 and 41 CFR 101-20.104-2); Rehabilitation Act of 1973, as amended, 29 U.S.C. 791; and the
ADA Amendment Act of 2008 authorize us to collect this information. We will use the information you
provide to help us determine reasonable accommodations. The information you provide is voluntary.
However, failure to provide the requested information may make it impossible for us to process your
request.
We rarely use the information you provide on this form for any purpose other than for the reasons
explained above. 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 Social
Security 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, General Services Administration, National
Archives Records Administration, and the 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 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 agencies 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.
A complete list of routine uses for this information is available in our Systems of Records Notices entitled,
Social Security Administration Parking Management Record System, 60-0230, and Reasonable
Accommodation for Persons with Disabilities (RAPD) 60-0315. The notices, additional information
regarding this form, and information regarding our system and programs, are available on-line at
www.socialsecurity.gov or at any local Social Security office.

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 (OMB) control number. The
OMB control number for this collection is 0960-0624. We estimate that it will take between 5 minutes 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 21235-6401.
Form SSA-3194 (03-2012)