Ssa 8510 Form – Fill Out and Use This PDF

Form SSA-8510 (06-2017) UF	Form Approved
Social Security Administration	OMB No. 0960-0801

AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION

TO OBTAIN PERSONAL INFORMATION

I authorize any public or private custodian of records to disclose to the Social Security Administration any records or information about me. In the case of a minor or incapable person, I, as guardian or representative, authorize the same disclosure of records about the person I represent.

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.

Form SSA-8510 (06-2017) UF

Privacy Act Statement

Collection and Use of Personal Information

Sections 205(a) and 1631(e) of the Social Security Act, as amended, authorize us to collect this information. We will use the information you provide on this form to obtain information about you from any public or private custodian regarding your eligibility for Social Security benefits.

You do not have to provide us this information. Your responses are voluntary. However, failure to provide all or part of the information could prevent us from making an accurate and timely decision regarding your Social Security benefits.

We rarely use this information you supply for any purpose other than for reviewing your claim for Social Security benefits. However, we may use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in accordance with approved routine uses, which include but are not limited to the following:

1.To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;

2.To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department of Veterans’ Affairs);

3.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and,

4.To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of Social Security programs.

We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify a person’s eligibility for Federally-funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.

A complete list of routine uses for this information are available in our System of Records Notices entitled, Claims Folders Systems (60-0089) and the Master Beneficiary Record (60-0090). These notices, additional information regarding this form, routine uses of information, and our programs and systems are available on-line at www.socialsecurity.gov or at your local Social Security office.

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 5 minutes to read the instructions, gather the facts, and answer the questions. Send only comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.