The checkbox shows the reason you are giving the Social Security Administration your authorization to contact financial institutions.
Eligibility box: The Social Security Administration will request records to determine initial or continuing eligibility and the accuracy of the payment for SSI benefits.
Waiver box: The Social Security Administration will request records to determine the ability to repay an overpayment in conjunction with a waiver determination.
Signed by mark: However, if you have signed by mark (X), two witnesses to the signing who know you must sign below giving their full addresses.
Revoking: I have the right to revoke this authorization at any time before any records are disclosed.
| Question | Answer |
|---|---|
| Form Name | Form SSA-4641 |
| Form Length | 5 pages |
| Fillable? | Yes |
| Fillable fields | 246 |
| Avg. time to fill out | 41 min |
| Edition | 10-2019 |
| Issuing agency | Social Security Administration |
| Matches the agency's file | Yes, checked October 1, 2026 |
| Other names | SSA-4641, SSA 4641, SSA4641, Form SSA-4641, SSA-4641-U2, Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution |
| Official source | Form SSA-4641 (Rev 10-2019), Social Security Administration |
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