Ssa 4641 U2 Form PDF Details

The Social Security Administration (SSA) meticulously assesses and periodically reviews the eligibility of individuals for Supplemental Security Income (SSI) to ensure that benefits are conferred accurately and fairly. A critical component in this process is the SSA-4641-U2 form, officially titled "Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records." This form serves multiple integral functions—it authorizes the SSA to request and receive financial records from a bank or another financial institution regarding an individual's or a joint account holder's financial status. The information gathered through this form is essential for determining both initial and ongoing eligibility for SSI benefits, and ensures the accuracy of payments to recipients. The form requires details such as the customer's name, Social Security number, account numbers, and the name and address of the financial institution, alongside signatures from the customer or their legal representative. Furthermore, it emphasizes the customer's rights in relation to the authorization, including the duration of the authorization, the right to revoke at any time, and guarantees the confidentiality of the obtained information. It is clear that the SSA-4641-U2 form is a pivotal tool in safeguarding the integrity of the SSI program, contributing to the reduction of incorrect payments and ultimately, saving taxpayer dollars, while also protecting the rights and privacy of the individuals involved.

QuestionAnswer
Form NameSsa 4641 U2 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameswho has to fillout the ssa 4641, ssa 4641 u2, e4641, ssa 4641 form pdf

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Form Approved

SOCIAL SECURITYADMINISTRATION

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 IF OTHER THAN CUSTOMER

SOCIAL SECURITY NUMBER

ACCOUNT NUMBER(S) (INDIVIDUAL OR JOINT)

,,

A request for records will be made by the Social Security Administration to determine initial or continuing eligibility and the accuracy of payment for Supplemental Security Income benefits. I understand that any information obtained will be kept confidential and that:

1.This authorization is valid for up to 3 months from the date of my signature; and

2.I have the right to revoke this authorization at any time before any records are disclosed; and

3.The Social Security Administration is requesting all records appearing on the attachment to this authorization, whether or not listed above; and

4.I have a right to 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

5.This authorization is not required as a condition of doing business with the financial institution named above; and

6.As a customer, my authorization is voluntary; however, if I am an applicant or recipient, failure to provide my signature below may result in a suspension or loss of benefits.

I authorize any custodian of records at the financial institution named above 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 benefit I manage.

CUSTOMER'S SIGNATURE

LEGAL REPRESENTATIVE'S OR REPRESENTATIVE PAYEE'S SIGNATURE

MAILING ADDRESS

DATE

 

 

REPRESENTATIVE'S MAILING ADDRESS

DATE

 

 

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.

SIGNATURE OF SOCIAL SECURITY ADMINISTRATION REPRESENTATIVE

TELEPHONE NO. (include area code)

DATE

ADDRESS

Form SSA-4641-U2 (8-94) Use until stock is exhausted

(1)

INFORMATION FOR THE FINANCIAL INSTITUTION

WHY THIS INFORMATION IS NEEDED

To ensure that supplemental security income (SSI) payments are made only to eligible persons, it is sometimes necessary to verify allegations about financial institution accounts. Experience has shown that the verification you provide is directly responsible for reducing the number of incorrect payments and results in savings to the taxpayer.

Most of the time we use the customer's records, but sometimes we check with you to:

•Discover other accounts which may not have been reported to us. SSA studies confirm that unreported accounts are discovered most often where a customer acknowledged having an account.

•Find out the exact balance of all accounts as of the first day of the month. Since we periodically review an individual's circumstances to ensure eligibility for SSI, we sometimes ask for balances covering more than a year.

•Ask about interest payments because SSI is a needs based program and we must know about all available income to determine if it affects eligibility or payment.

IMPORTANT REMINDER ITEMS

Page 1: Make sure that the customer(s) (or representative) and the SSA representative have signed and dated the form. If a signature is missing, call the SSA office shown.

Page 3: Part I--Read this to find out which accounts need to be verified. If the customer owns other accounts which are not shown in part I. please also provide the information needed about these accounts.

Part II--Read this to find out what information is needed to verify those accounts.

Page 4: Use this page to furnish the verifying information.

Note: The information is needed even if the account has been closed. Please show the following formation in:

Part A: The type of account, account number, and designation exactly as shown on the account.

Part B: 1. The opening balance(s) as of the first day of the month(s) listed. If your records show only closing balances, enter the closing balance for the last day of the previous month.

2.The amount of interest paid or credited the account(s) in each month listed.

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB control number.

Time It Takes To Complete This Form:

We estimate that it will take you about 6 minutes to complete this form. This includes the time it will take to read the instructions, gather the necessary facts and fill out the form. If you have comments or suggestions on this estimate, write to the Social Security Administration, ATTN: Reports Clearance Officer, 1-A-21 Operations Bldg., Baltimore, MD 21235. Send only comments relating to our “time it takes” estimate to the office listed above. All requests for Social Security cards and other claims-related information should be sent to your local Social Security office, whose address is listed under Social Security Administration in the U.S. Government section of your telephone directory.

We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.

Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security Offices. If you want to learn more about this, contact any Social Security Office.

PLEASE BE SURE TO SIGN AND DATE THE FORM AND RETURN IT IN THE ENVELOPE PROVIDED.

ADDITIONAL INFORMATION/REMARKS FROM SSA

Form SSA-4641-U2 (8-94)

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REQUEST FOR RECORDS

 

 

 

 

 

 

 

PART I–FOR COMPLETION BY THE SOCIAL SECURITY REPRESENTATIVE

 

 

 

 

 

 

 

 

Customer's Name

 

Customer's Social Security Number

 

 

 

 

 

 

 

 

Financial Institution Name and Address

 

Applicant/Recipient If Not Customer

 

 

 

 

 

 

 

 

 

 

 

Social Security Number

 

 

 

 

 

 

 

 

Account Numbers(s) (Individual or Joint)

 

 

 

 

 

 

,

 

,

 

The financial institution is requested to provide information in Part II for the period____/____through____/____for the account

number(s) listed above, whether “active” or “inactive/closed,” and any others, such as certificates of deposit, etc., held (individually or jointly) by the above named customer or applicant/recipient.

PART II–FOR COMPLETION BY THE FINANCIAL INSTITUTION REPRESENTATIVE

This request is authorized by sections 1631 (e)(1)(B), 1102, and 403j of the Social Security Act, as amended. While you are not required to respond, your cooperation will help us determine the eligibility of the applicant or recipient named below for Supplemental Security Income benefits. The customer's authorization for release of the information contained in your records appears on the attachment to this form.

INSTRUCTIONS FOR COMPLETION:

•Refer to Part I above for information about the accounts to be verified

•Spaces are available for up to three accounts. If there are more than three accounts, provide information in the “Remarks” section or attach a separate sheet of paper. Note: copies of bank records, including computer printouts, are acceptable in lieu of manual entries on the form.

•IN ALL CASES, A FINANCIAL INSTITUTION REPRESENTATIVE’S SIGNATURE MUST APPEAR IN THE SPACES PROVIDED AT THE END OF THIS FORM. A postage free return envelope is enclosed for your convenience.

•If no accounts are located, check box in section A, page 4, and sign where indicated.

REMARKS

Form SSA-4641-U2 (8-94)

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Customer's

 

Social Security

 

Name:

 

Number:

 

A.

ACCOUNT 1

ACCOUNT 2

ACCOUNT 3

Type of Account*

 

 

 

 

 

 

 

Account Number

 

 

 

Name(s) On

and Exact

Account

Designation

No accounts were located for this customer.

*Checking, Savings, Time/Certificate of Deposit, IRA, Keogh, Trust, Etc.

B.Provide the information in the box(es) checked for the months indicated. Copies of account records may be submitted in lieu of entering data below.

1. Opening Balance(s) As Of the First Day of the Month for Each Account (or Balance on the Close of Business of the Last Day of the Previous Month).

2. The Amount of Interest Paid or Credited During Each Month.

 

ACCOUNT 1

 

 

ACCOUNT 2

ACCOUNT 3

 

 

 

 

Interest

 

 

Interest

 

 

 

Interest

Month/Year

Balance

 

Paid

 

Balance

Paid

 

Balance

 

Paid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Financial Institution Representative

Phone Number

 

(

)

 

 

 

 

Date

 

 

 

 

Form SSA-4641-U2 (8-94)

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1. It's very important to complete the ssa form 4641 accurately, thus be careful while filling in the sections containing these particular blanks:

ssa 4641 u2 completion process clarified (stage 1)

2. Once your current task is complete, take the next step – fill out all of these fields - I authorize any custodian of, CUSTOMERS SIGNATURE, MAILING ADDRESS, DATE, LEGAL REPRESENTATIVES OR, REPRESENTATIVES MAILING ADDRESS, DATE, Your authorization does not, SIGNATURE OF WITNESS, ADDRESS Number Street City State, ADDRESS Number Street City State, I CERTIFY that the applicable, SIGNATURE OF SOCIAL SECURITY, TELEPHONE NO include area code, and DATE with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Part no. 2 of filling out ssa 4641 u2

Always be very attentive while filling in DATE and MAILING ADDRESS, as this is the section where most people make a few mistakes.

3. This next segment will be about ADDRESS, and Form SSAU Use until stock is - fill out all these blank fields.

Part # 3 for filling out ssa 4641 u2

4. You're ready to fill in this next form section! In this case you've got these PLEASE BE SURE TO SIGN AND DATE, ADDITIONAL INFORMATIONREMARKS FROM, and Form SSAU empty form fields to complete.

Part number 4 of completing ssa 4641 u2

5. This document should be finished by filling in this segment. Below there is a detailed listing of blank fields that require correct information for your form submission to be complete: Customers Name, Customers Social Security Number, Financial Institution Name and, ApplicantRecipient If Not Customer, Social Security Number, Account Numberss Individual or, The financial institution is, PART IIFOR COMPLETION BY THE, This request is authorized by, and INSTRUCTIONS FOR COMPLETION cid cid.

Filling out part 5 of ssa 4641 u2

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