Form SSA-8420 Authorization for the Social Security Administration to

Form SSA-8240 (02-2017) SOCIAL SECURITY ADMINISTRATION Form Approved OMB No. 0960-XXXX
	AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN WAGE AND EMPLOYMENT INFORMATION FROM PAYROLL DATA PROVIDERS
	Individual Whose Wage and Employment Information Will Be Obtained	Social Security Number (for individual)
	Claimant/Beneficiary (If different from above)	Claimant/Beneficiary Social Security Number (If different from above)
3.	I understand: Section 1184 of the Social Security Act (Act) authorizes the Social Security Administration (SSA) to enter into information exchanges with payroll data providers. SSA will use my authorization to obtain wage and employment information from payroll data providers. Section 1184(c)(1) of the Act defines a payroll data provider as payroll providers, wage verification companies, and other entities that collect and maintain data about employment and wages. If SSA obtains payroll data provider records about me based on this authorization, it may use the records for purposes other than for the program that the authorization covers. For example, SSA may use my records to decide whether I can get benefits under both the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) programs, even if this authorization is limited to one program. Additional information about how SSA may use and disclose my records is in the Privacy Act Statement below. SSA will request authorization under the SSDI and SSI programs. SSA will request authorization once under each program, even if I have multiple SSDI or SSI claims. However, SSA may use my authorization to obtain payroll data provider records about me for any claims associated with the ones I file, such as a claim for benefits by my spouse or child. If I revoke my authorization, SSA will not use the authorization to obtain my information for any of my claims under both programs. By authorizing the SSA to obtain my wage and employment information, I will receive protection from certain penalties, pursuant to section 1129A of the Act.  I further understand that if I later revoke my authorization, I will no longer get this protection. Not all employers report wage and employment information to payroll data providers that SSA uses.  If my employer does report, SSA will request my wage and employment information from the payroll data provider.  I am still responsible for making sure that my wage and employment information are reported accurately to SSA. If we paid you too much in benefits because the payroll data provider reported your wage and employment information inaccurately, you may have to pay us back. If my employer does not report or stops reporting to a payroll data provider that SSA uses, I will have to report my wage and employment information. I am authorizing payroll data providers (as defined in section 1184 of the Act) to disclose to the SSA data about me or that of the person named above whom I legally represent.
3.a	Answer questions (3.b and 3.c) below by checking Yes or No. NOTE: If you are filing or receiving benefits under SSDI and SSI, you must answer both questions.
3.b	Do you give us authorization to obtain your wage and employment information from payroll data providers for the Social Security Disability Insurance (SSDI) program? Your authorization will help us determine whether you are entitled to benefits, or continue to be entitled to benefits. Giving us your authorization may also help us avoid paying the wrong amount. We will ask for all of your records held by the payroll data provider whenever we determine that we need these records to make decisions on your entitlement to benefits. Your authorization will remain in effect until: We make a final adverse decision on your application for benefits and no other claims or appeals are pending; Your entitlement to benefits ends and no other claims or appeals are pending; or You revoke your authorization in writing.		SSDI  YES  NO
3.c	Do you give us authorization to obtain your wage and employment information from payroll data providers for the Supplemental Security Income (SSI) program? Your authorization will help us determine whether you or the person who filed an application for benefits, is eligible for SSI, or continues to be eligible for SSI. Giving us your authorization may also help us avoid paying the wrong amount. We will request your records held by the payroll data provider whenever we determine that we need these records to make decisions on your eligibility for SSI. Your authorization will remain effective until: We make a final adverse decision on the application for benefits and no other claims or appeals are pending; You or the other person’s eligibility for payments ends and no other claims or appeals are pending; You revoke your authorization in writing; or We no longer count your income and resources to the other person.		SSI  YES  NO
4.	PLEASE SIGN IN BLACK OR BLUE INK ONLY INDIVIDUAL authorizing disclosure SIGN	If not signed by the individual whose wage and employment information will be obtained, what is the basis for the authority to sign Parent of minor Guardian Print name of parent/guardian
Date Signed		Mailing Address of individual authorizing disclosure
City		State	Zip Code
5.	Your authorization does not ordinarily have to be witnessed. However, if you have signed using a mark, two witnesses to the signing who know you must sign below giving their full addresses. If needed, WITNESS I know the person signing this form or am satisfied of this person’s identity:
	SIGN	If needed, second witness sign here (e.g., if signed with a mark above) SIGN
	Mailing Address for Witness 1	Mailing Address for Witness 2
PRIVACY ACT STATEMENT COLLECTION AND USE OF INFORMATION ON YOUR AUTHORIZATION FORM Sections 205(a), 225, 1184, and 1631(e) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from making an accurate and timely decision regarding your Social Security benefits. We will use the information you provide to obtain information about you from payroll data providers. We will use the payroll data provider information to administer the Social Security Act, such as determining your eligibility for Social Security benefits. We may also share your information for the following purposes, called routine uses: To contractors and other Federal agencies as necessary, for the purpose of assisting Social Security Administration (SSA) in the efficient administration of its programs. We contemplate disclosing information under this routine use only in situations in which SSA may enter a contractual or similar agreement with a third party to assist in accomplishing an agency function. To employers or former employers for correcting or reconstructing earnings records and for Social Security tax purposes only. In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs. A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0089, entitled Claims Folders Systems and 60-0090, entitled Master Beneficiary Record. Additional information and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook. 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 5 minutes to read the instructions, gather the facts, and answer the questions. Send only comments on our time estimate above to: Social Security Administration, 6401 Security Blvd., Baltimore, MD 21235-6401.
Form SSA-8240