Form SSA-4641-U2 Authorization for the Social Security Administration to

Form Approved
OMB No. 0960-0293

Social Security Administration

AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION TO OBTAIN ACCOUNT
RECORDS FROM A FINANCIAL INSTITUTION AND REQUEST FOR RECORDS
CUSTOMER'S NAME

SOCIAL SECURITY NUMBER

NAME AND ADDRESS OF FINANCIAL INSTITUTION

APPLICANT/RECIPIENT/BENEFICIARY IF
OTHER THAN CUSTOMER

ACCOUNT NUMBER(S)
JOINT ACCOUNT

DIRECT DEPOSIT

JOINT ACCOUNT

JOINT ACCOUNT

DIRECT DEPOSIT

DIRECT DEPOSIT

,

,

I understand:
• I have the right to revoke this authorization at any time before any records are disclosed;
• The Social Security Administration may request all records about me from any financial institution;
• Any information obtained will be kept confidential;
• I have the right to obtain a copy of the record which the financial institution keeps concerning the instances when it
has disclosed records to a government authority unless the records were disclosed because of a court order; and
• This authorization is not required as a condition of doing business with any financial institution.
The checkbox below shows the reason you are giving us your authorization to contact financial institutions:
Supplemental Security Income Eligibility
• The Social Security Administration will request records to determine initial or continuing eligibility and the accuracy
of the payment for Supplemental Security Income (SSI) benefits.
• If I am an applicant or recipient, failing to provide or revoking my authorization will result in a denial or suspension
of SSI benefits.
• If I am a person whose income and resources the Social Security Administration considers as being available to
an applicant or recipient, failing to provide or revoking my authorization may result in a denial of benefits for the
applicant or a suspension of benefits for the recipient.
• This authorization is in effect until the earliest of: 1) a final adverse decision on my application for benefits, 2) the
cessation of my eligibility for benefits, or 3) my revocation of this authorization in a written notification to the Social
Security Administration.
Waiver Determination
• The Social Security Administration will request records to determine the ability to repay an overpayment in
conjunction with a waiver determination.
• Failing to provide or revoking my authorization may result in the Social Security Administration determining, on
that basis, that adjustment or recovery of the overpayment will not deprive me of funds to pay my bills for food,
clothing, housing, medical care, or other necessary expenses.
• This authorization is in effect until the earliest of: 1) a final decision on whether adjustment or recovery of my
overpayment would deprive me of funds to pay my bills for food, clothing, housing, medical care, or other
necessary expenses; or 2) my revocation of this authorization in a written notification to the Social Security
Administration.
I authorize any custodian of records at this financial institution to disclose to the Social Security Administration any records
about my financial business or that of the person named above whom I legally represent or whose benefits I manage.
CUSTOMER'S SIGNATURE/AUTHORIZATION

MAILING ADDRESS

DATE

LEGAL REPRESENTATIVE'S SIGNATURE /
AUTHORIZATION

LEGAL REPRESENTATIVE'S MAILING
ADDRESS

DATE

Form SSA-4641(01-2016) UF (01-2016)
Destroy Prior Editions

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Customer's Name:

Social Security Number:

Your authorization does not ordinarily have to be witnessed. However, if you have signed by mark (X), two witnesses to the
signing who know you must sign below giving their full addresses.
1. SIGNATURE OF WITNESS

2. SIGNATURE OF WITNESS

ADDRESS (Number, Street, City, State, Zip Code)

ADDRESS (Number, Street, City, State, Zip Code)

I CERTIFY that the applicable provisions of the Right to Financial Privacy Act of 1978 (12 U.S.C. 3401-3422) have been
complied with in this request. Pursuant to the Right to Financial Privacy Act of 1978, good faith reliance upon this
certification relieves your institution and its employees and agents of any possible liability to the customer in connection with
the disclosure of these financial records.
AUTHORIZATION OF SOCIAL SECURITY
ADMINISTRATION REPRESENTATIVE

TELEPHONE NO.
(INCLUDE AREA CODE)

DATE

ADDRESS

REQUEST FOR RECORDS
This request is authorized by sections 204(b), 1631(b)(1)(B) and 1631 (e)(1)(B) of the Social Security Act, as amended.
While you are not required to respond, your cooperation will help us either to: (1) determine the eligibility of the applicant or
recipient named above for Supplemental Security Income benefits; or (2) determine if a request to waive a Social Security
overpayment should be granted. The customer's authorization for release of the information contained in your records
appears on page one of this form.
Please provide information for the period
through
for the account number(s) listed
above and any others held (either individually or jointly) by the above named customer.
SSA REMARKS

Form SSA-4641 (01-2016) UF (01-2016)

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Customer's Name:

Social Security Number:

FOR COMPLETION BY THE FINANCIAL INSTITUTION REPRESENTATIVE
INSTRUCTIONS FOR COMPLETION

•
•
•
•
•
•

Refer to page one for information concerning the accounts to be verified. If the customer owns other accounts that are
not listed, please provide information on those accounts for the time frame requested.
We need account information even if the account has been closed or the account number has changed.
Spaces are available for up to three accounts. If there are more than three accounts, please provide information on a
separate sheet of paper.
Please include at the end of this form the name of the financial institution representative providing account information.
Please return this form and all supporting materials to the Social Security Administration in the postage free return
envelope provided.
If no accounts are located, check the box below where indicated.
ACCOUNT 1

ACCOUNT 2

ACCOUNT 3

TYPE OF ACCOUNT 1
ACCOUNT NUMBER

NAME(S) ON AND EXACT
ACCOUNT DESIGNATION
1 Checking, Savings, Time/Certificate of Deposit, Keogh, IRA, UGMA/UTMA, Escrow, Etc.
No accounts were located for this customer.

•
•

Copies of account records may be submitted in lieu of entering data below.
For all accounts, provide opening balances as of the first day of the month for each account, for each month listed
in the period.
Unless this box is checked, do not provide interest paid or credited during each month.
ACCOUNT 1

Month/Year

Balance

Form SSA-4641 (01-2016) UF (01-2016)

ACCOUNT 2
Interest
Paid

Balance

Page 3

ACCOUNT 3
Interest
Paid

Balance

Interest
Paid

Customer's Name:

Social Security Number:

ACCOUNT 1
Month/Year

Balance

ACCOUNT 2
Interest
Paid

Balance

Name of Financial Institution Representative

ACCOUNT 3
Interest
Paid

Phone Number
Date

REMARKS

Form SSA-4641 (01-2016) UF (01-2016)

Balance

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Interest
Paid

Privacy Act Statement
Collection and Use of Personal Information

See Revised Privacy Act
Statement Attached.

Sections 204(a) and (b), 1631(b)(1)(B), and 1631(e)(1)(B) of the Social Security Act, as amended,
allow us to collect this information. We may use the information you provide to determine the eligibility
of the applicant or recipient named above for Supplemental Security Income benefits. Or, we may use
the information to assist us in determining whether to waive a Social Security overpayment because
adjustment or recovery would defeat the purpose of the Social Security Act.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from making an accurate and timely decision on eligibility, or could result in
the loss of benefits. Or, failing to provide the information may prevent us from waiving an overpayment.
We rarely use the information you supply for any purpose other than what we state above, however, we
may use the information for the administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the
Government Accountability Office and Department of Veterans Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to private
entities under contract with us); and,
A complete list of when we may share your information with others, called routine uses, are available in
our Privacy Act System of Records Notices 60-0094, entitled Recovery of Overpayments, Accounting
and Reporting/ Debt Management System, and 60-0103, entitled Supplemental Security Income
Records and Special Veterans Benefits. Additional information about this and other system of records
notices and our programs are available from our Internet website at www.socialsecurity.gov or at your
local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or local
government agencies. We use the information from these programs to establish or verify a person's
eligibility for federally funded or administered benefit programs and for repayment of incorrect
payments or delinquent debts under these programs.
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 6 minutes to read the instructions, gather the facts, and answer the
questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address,
not the completed form.

Form SSA-4641 (01-2016) UF (01-2016)

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