Authorization for SSA to Obtain Account Records From A Financial Institution And Request For Records - Individuals (Paper and Electronic)

SSA will insert the following revised Privacy Act & PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

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 determining if the individual has the ability to repay an
overpayment.
We will use the information you provide 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:
•

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. We
will disclose information under the routine use only in situations in which SSA may enter
into a contractual or similar agreement with a third party to assist in accomplishing an
agency function relating to this system of records; and

•

To student volunteers, individuals working under a personal services contract, and other
workers who technically do not have the status of Federal employees, when they are
performing work for the Social Security Administration (SSA), as authorized by law, and
they need access to personally identifiable information in SSA records in order to
perform their assigned Agency functions.

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
(SORNs) 60-0090, entitled Master Beneficiary Record, as published in the Federal Register (FR)
on January 11, 2006, at 71 FR 1826; 60-0094, entitled Recovery of Overpayments, Accounting
and Reporting/Debt Management System (ROAR/DMS), as published in the FR on August 23,
2005, at 70 FR 49354; 60-0103, entitled Supplemental Security Income Record and Special
Veterans Benefits, as published in the FR on January 11, 2006, at 71 FR 1830; and 60-0320
entitled Electronic Disability (eDIB) Claim File, as published in the FR on June 4, 2020, at 85
FR 34477. Additional information, and a full listing of all 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
(OMB) control number. We estimate that it will take about 6 minutes to read the instructions,
gather the facts, and answer the questions. Send only comments regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.