Form Ssa-8510 - Authorization For The Social Security Administration To Obtain Personal Information

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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
Authorizing Person (Person about whom information is being requested)
Social Security Number
Claimant/Beneficiary (If other than authorizing person)
Claimant's/Beneficiary's Social Security Number
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.
Authorizing Person's Signature
Date
Mailing Address
City and State
ZIP Code
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.
1. Signature of Witness
2. Signature of Witness
Address (Number, Street, City, State, ZIP Code)
Address (Number, Street, City, State, ZIP Code)

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