Form Ssa-3288 - Consent For Release Of Information - Social Security Administration Page 2
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1
2Form Approved
OMB No. 0960-0566
Social Security Administration
Consent for Release of Information
TO: Social Security Administration
Name
Date of Birth
Social Security Number
I authorize the Social Security Administration to release information or records about
me to:
NAME
ADDRESS
I want this information released because
:
(There may be a charge for releasing information.)
Please release the following information:
Social Security Number
Identifying information (includes date and place of birth, parents' names)
Monthly Social Security benefit amount
Monthly Supplemental Security Income payment amount
Information about benefits/payments I received from
to
Information about my Medicare claim/coverage from
to
(specify)
Medical records
Record(s) from my file (specify)
Other (specify)
I am the individual to whom the information/record applies or that person's parent (if a
minor) or legal guardian. I declare under penalty of perjury that I have examined all the
information on this form and it is true and correct to the best of my knowledge. I
understand that anyone who knowingly gives a false or misleading statement about a
material fact in this information, or causes someone else to do so, commits a crime and
may be sent to prison, or may face other penalties, or both.
Signature:
(Show signatures, names, and addresses of two people if signed by mark.)
Date:
Relationship:
Form SSA-3288 (3-2005) EF (3-2005)
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