Form Ssa-3288 - Consent For Release Of Information printable pdf download

Form Ssa-3288 - Consent For Release Of Information

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:

Bail Bond

Agency: __________________________________________________________________________

I want this information released because:

The records will be used for the purpose of securing reimbursement for any expense and/or/ his/her appearance or

nonappearance and/or apprehension for court appearance

(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

_____

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)

_____

Present Employment

_____

Other (specify) ___________________________________________________________

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.

Signature: _________________________________________________________________________

(Show signatures, names, and addresses of two people if signed by mark).

Date:

___________________________ Relationship: Bail Bondsman/Bonding Agency

SSA-3288 Internet (12/99)

Form Ssa-3288 - Consent For Release Of Information