Form Ssa-3288 - Consent For Release Of Information - 2013

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Social Security Administration
Form Approved
Consent for Release of Information
OMB No. 0960-0566
You must complete all required fields. We will not honor your request unless all required fields are completed. (*signifies a
required field).
TO: Social Security Administration
*My Full Name
*My Social Security Number
*My Date of Birth
(MM/DD/YYYY)
I authorize the Social Security Administration to release information or records about me to:
*NAME OF PERSON OR ORGANIZATION:
*ADDRESS OF PERSON OR ORGANIZATION:
Barb Tucker
Work Incentive Planning & Assistance
Illinois Assistive Technology Program
1020 S. Spring Street
Fax: 217-321-0967
Springfield IL 62704
*I want this information released because:
I am planning to go to work and need the information for
We may charge a fee to release information for non-program purposes.
benefits and work incentives planning. Please send a Benefits Planning Query.
*Please release the following information selected from the list below:
You must specify the records you are requesting by checking at least one box. We will not honor a request for "any and all
records" or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested.
1.
Social Security Number
2.
Current monthly Social Security benefit amount
3.
Current monthly Supplemental Security Income payment amount
4.
My benefit or payment amounts from date
to date
5.
My Medicare entitlement from date
to date
6.
Medical records from my claims folder(s) from date
to date
If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social
Security office.
7.
Complete medical records from my claims folder(s)
8.
Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application,
determination or questionnaire)
My cash benefits, health insurance information, medical review dates, representation, SSDI
and SSI work activity and earnings. All employment supports data on my SSA record.
I am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or
the legal guardian of a legally incompetent adult. I declare under penalty of perjury (28 CFR § 16.41(d)(2004)) that I have
examined all the information on this form, and any accompanying statements or forms, and it is true and correct to the
best of my knowledge. I understand that anyone who knowingly or willfully seeks or obtain access to records about
another person under false pretenses is punishable by a fine of up to $5,000. I also understand that I must pay all
applicable fees for requesting information for a non-program-related purpose.
*Date:
*Signature:
*Address:
Relationship (if not the subject of the record):
*Daytime Phone:
Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing
who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the
signature line above.
2.Signature of witness
1.Signature of witness
Address(Number and street,City,State, and Zip Code)
Address(Number and street,City,State, and Zip Code)
Form SSA-3288 (07-2013) EF (07-2013)

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