Form SSA-2935 Authorization to the Social Security Administration to O

Form SSA-2935 (08-2018)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0189

AUTHORIZATION TO THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN PERSONAL
INFORMATION
BENEFICIARY'S NAME:

SOCIAL SECURITY NUMBER: XXX-XXSTREET ADDRESS:

STATE:

CITY:

ZIP CODE:

I authorize the Individual, Organization, or Agency listed below to disclose to the Social Security Administration information
about me relating to my Social Security benefits. I understand that this information will be kept confidential as required by the
Social Security Act and the Privacy Act of 1974. This authorization shall remain in effect for no longer than 12 months from the
date of my signature.
Name of Individual, Organization, or Agency:
Address:

State:

City:

Signature of Beneficiary (First name, middle initial, last name)
(Write in ink)

Zip Code:

Date (Month, day, year)

SIGN
HERE

Signature of Representative Payee or Guardian
(Write in ink)

(First name, middle initial, last name)

Date (Month, day, year)

SIGN
HERE

Witnesses are required ONLY if this authorization has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the applicant must sign below, giving their full addresses.
Signature of Witness

(First name, middle initial, last name)

Date (Month, day, year)

(First name, middle initial, last name)

Date (Month, day, year)

(Write in ink)
SIGN HERE
ADDRESS

Signature of Witness
(Write in ink)
SIGN HERE
ADDRESS

Form SSA-2935 (08-2018)

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Privacy Act Statement
Collection and Use of Personal Information
Section 205(a) 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 on your claim.
We will use the information to review your claim. We may also share your information for the
following purposes, called routine uses:
1. To third party contacts in situations where the party to be contacted has, or is expected
to have, information relating to the individual's capability to manage their affairs or
eligibility for or entitlement to benefits under the Social Security program when the data
are needed to establish the validity of evidence or to verify the accuracy of information
presented by the individual; and
2. To applicants, claimants, prospective applicants or claimants, other than the data
subject, their authorized representatives or representative payees to the extent
necessary to pursue Social Security claims and to representative payees when the
information pertains to individuals for whom they serve as representative payment
responsibilities under the Act and assisting the representative payees in performing their
duties as payees, including receiving and accounting for benefits for individuals for
whom they serve as payees.
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 Notices
(SORN) 60-0089, entitled Claims Folders Systems. 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 to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401