Consent For Release Of Information

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Consent for Release of Information
by the Social Security Administration
INSTRUCTIONS
Supplemental Security Income (SSI) benefit recipient:
Please complete Sections 1, 2, and 4 and MAIL
THIS FORM TO THE “OFFICE LOCATION” YOU LIST IN SECTION 1.
SECTION 1:
List the complete office location (address) below that assisted you with your Supplemental Security
Income (SSI) benefits. To locate the address, visit
and click on “Find a Social Security Office” from the
left menu, and type in the zip code. Write that address below.
Office location:
Street address: ______________________________________________________________________________
City, state, and zip: ___________________________________________________________________________
SECTION 2:
Name of SSI benefit recipient (please print): ______________________________________________________
____________________________________
_____________________________________________________
Date of Birth
Social Security Number
Month and year you were hired: ___________________________________________________________
*
This is the month and year you were hired with the employer for whom you completed forms for the Work Opportunity Tax Credit (WOTC) Program.
SECTION 3:
I authorize the Social Security Administration to release information and supply, using this document, the specific
information requested in the table below to the agency/representative listed as:
State WOTC Coordinator – Job Service North Dakota Workforce Programs - PO Box 5507 - Bismarck ND 58506-5507
for the purpose of establishing eligibility for the Work Opportunity Tax Credit (WOTC) Program.
THIS TABLE IS TO BE COMPLETED BY THE SOCIAL SECURITY ADMINISTRATION.
Were SSI benefits received by the recipient listed in Section 2 during the following months:
Supplemental
The month prior to
The month that is 2 months
*
The
hire month
Security Income
*
*
as listed in Section 2:
the
hire month:
prior to the
hire month:
(SSI) Benefits
Yes
No
Yes
No
Yes
No
SECTION 4: SSI BENEFIT RECIPIENT: PLEASE SIGN BELOW AND MAIL THIS FORM TO
THE OFFICE YOU LISTED IN SECTION 1.
I am the individual to whom the information/record applies or that person’s parent (if a minor) or legal guardian. I know that if I make any
representation which I know is false to obtain information from Social Security records, I could be punished by a fine or imprisonment or both.
I understand this Consent for Release of Information form is valid for one year from the date I indicate below. If no date is indicated, it will be
valid for one year upon receipt by the Social Security Administration.
____________________________________________________
____________________________________
Signature
Date
__________________________
If the person signing the form is not the individual whose record will be released, list your relationship:

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