Form SSA-3194 Renewal Certification

Form SSA-3194 (XX-2017)
Discontinue Prior Editions
Social Security Administration

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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 section 501(g) of the
Rehabilitation Act of 1973, as amended, 29 U.S.C. 791(g). 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 Director, Office of Security
Administration and Project Management, by fax to (410) 597-0455 or bring to servicing Parking and
Credentialing Office with your expiring permit. If you have any questions, you may contact the Medical
Parking Office at (410) 966-8814.
1. Name (last, first, middle initial):

2. Last four digits of SSN:

3. Office/Company

4. Work Schedule:

5. Building/Room No.:

Renewal Certification

Signature:

6. Identify current
parking space:

6a. Area:

6b. Lane:

6c. 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 Director, Office of Security Administration and Project Management,
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 servicing Parking and Credentialing Office.
Date:

Telephone Number:

Form SSA-3194 (XX-2017)

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Permanent Medical Parking Renewal Certification
In Connection with Medical Parking at SSA Headquarters Buildings 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); section 501(g) of the Rehabilitation Act of 1973, as amended, 29 U.S.C.
791(g) as amended 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.