SSA-2935 - Current

Form SSA-2935 (08-2018)
Discontinue Prior Editions
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Social Security Administration
OMB No. 0960-0189
AUTHORIZATION TO THE SOCIAL SECURITY ADMINISTRATION
TO OBTAIN PERSONAL INFORMATION
BENEFICIARY'S NAME:
SOCIAL SECURITY NUMBER:
STREET ADDRESS:
CITY:

STATE:

ZIP CODE:

I authorize the Individual, Organization, or Agency listed below to disclose to the Social Security
Administration information about me relating to a claim for 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:
City:

State:

ZIP Code:

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

Date (Month, day, year)

Signature of Representative Payee or Guardian
(First name, middle initial, last name) (Write in ink)

Date (Month, day, year)

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) (Write in ink) Date (Month, day, year)
Address
Signature of Witness (First name, middle initial, last name) (Write in ink) Date (Month, day, year)
Address

Form SSA-2935 (08-2018)

Privacy Act Statement

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Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, allows 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 manager 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 your information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may used 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 benefits 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. 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 relating to our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401.