Form SSA-4641 Authorization for the Social Security Administration to

Form SSA-4641 (10-2019) UF
Destroy Prior Editions
Social Security Administration

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OMB No. 0960-0293

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

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Form SSA-4641 (10-2019) UF
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
and any others held (either individually or jointly) by the above named customer.
SSA REMARKS

for the account number(s) listed above

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Form SSA-4641 (10-2019) UF
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
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

ACCOUNT 2
Interest
Paid

Balance

ACCOUNT 3
Interest
Paid

Balance

Interest
Paid

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Form SSA-4641 (10-2019) UF
Customer's Name:

Social Security Number:

ACCOUNT 1
Month/Year

Balance

Name of Financial Institution Representative

ACCOUNT 2
Interest
Paid

Balance

ACCOUNT 3
Interest
Paid

Phone Number
Date

REMARKS

Balance

Interest
Paid

Form SSA-4641 (10-2019) UF

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See Revised Privacy Act &
Privacy Act Statement
Collection and Use of Personal Information PRA Statements attached

Sections 204(b), 1631(b)(1)(B), and 1631(e)(1)(B) 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 benefit eligibility or from waiving
an overpayment.
We will use this information to verify eligibility for benefits or to assist us in waiving a Social Security
overpayment. We may also share your information for the following purposes, called routine uses:

• Disclosure to contractors and other Federal agencies, as necessary, for the purpose of assisting
the Social Security Administration (SSA) in the efficient administration of its programs; and
• To student volunteers and other workers, who technically do not have the status of Federal
employees, when they are performing work for SSA.
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) 60-0094,
entitled Recovery of Overpayments Accounting and Reporting/Debt Management System, as published in
the Federal Register (FR) on August 23, 2005, at 70 FR 49354 and 60-0103, entitled Supplemental Security
Income Record and Special Veterans Benefits, as published in the FR on January 1, 2006, at 71 FR 1830.
Additional information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.

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.