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Fill and Sign the Form Ssa 3288 Social Security Administration Consent for

Fill and Sign the Form Ssa 3288 Social Security Administration Consent for

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Form A pproved O M B N o. 0960 -0566 Social Security A dministration Consent for Release of Information TO : So cial Security A d ministratio n Name _________________Date o f Birt h_______So cial Security Number_______________ I autho rize the So cial Security A d ministratio n to r elease info rmatio n o r reco rd s abo ut me to : NA ME A DDRESS I w ant this info rmatio n released because: (There may be a charge fo r releasing info rmatio n.) Please release the fo llo w ing info rmatio n: So cial Security Number Id entifying info rmatio n (includ es d ate and p lace o f birth, p arents' names) Mo nthly So cial Security benefit amo unt Mo nthly Sup p lemental Security Inco me p ayment amo unt Info rmatio n abo ut benefits/ p ayments I received fro m to _______ Info rmatio n abo ut my Med icare claim/ co verage fro m to _______ (sp ecify) Med ical reco rd s Reco rd (s) fro m my file (sp ecify) Other (sp ecify) I am the ind ivid ual to w ho m the info rmatio n/ reco rd ap p lies o r that p erso n's p arent (if a mino r) o r legal guard ian. I kno w that if I make any rep resentatio n w hich I kno w is false to o btain info rmatio n fro m So cial Security reco rd s, I co uld be p unished by a fine o r imp riso nment o r bo th. Signature: (Sho w signatures, names, and ad d resses o f tw o p eo p l e if signed by mark.) Date: Relatio nship : _________________ SSA-3288 Internet (12/99) Social Security A dministration Consent for Release of Information Please read these instructio ns carefully befo re co m p leting this fo rm. When To Use Co mp lete this fo rm o nly i f yo u w ant the So cial Security This Form A d ministratio n to give info rmatio n o r reco rd s abo ut yo u to an ind ivid ual o r gro up (fo r examp le, a d o cto r, o r i nsurance co mp any). Natural o r ad o p tive p arents o r a legal guard ian, acting on behalf of a minor, w ho w ant us to release the mino r's: o no nmed ical reco rd s, sho uld use this fo rm. o med ical reco rd s, sho uld no t use this fo rm, but sho uld co ntact us. No te: Do no t use this fo rm to request info rmatio n abo ut yo ur earnings o r emp lo yment histo ry. To d o this, co mp lete Fo rm SSA-7050 -F3. Yo u can get this fo rm at any So cial Security o ffice. How To This co nsent fo rm must be co mp leted and signed o nly by: Complete o the p erso n to w ho m the info rmatio n o r reco rd ap p lies, o r This Form o the p arent o r legal guard ian o f a mino r to w ho m the nonmedical info rmatio n ap p lies, o r o the legal guard ian o f a legally inco mp etent ad u lt to w ho m the info rmatio n ap p lies. To co mp lete this fo rm: o Fill in the name, d ate o f birth, and So cial Security Number o f the p erso n to w ho m the info rmatio n ap p lies. o Fill in the name and ad d ress o f the ind ivid ual o r gro up to w hich w e w ill send the info rmatio n. o Fill in the reaso n yo u are request ing the info rmatio n. o Check the typ e(s) o f info rmatio n yo u w ant us to release. o Sign and d ate the fo rm. If yo u are no t the p er so n w ho se reco rd w e w ill release, p lease state yo ur rela tio nship to that p erso n. The Pap erw o rk Red uc tio n A ct o f 1995 requires us to no tify yo u that thi s info rmatio n co llectio n is in acco rd ance w ith the clearance requirements o f sectio n 3507 o f the Pap er w o rk Red uctio n A ct o f 1995. W e may no t co nd uct o r sp o nso r, and yo u are no t req uired to resp o nd to , a co llectio n o f info rmatio n unless it d isp lays a valid OMB co ntro l number. TIME IT TA KES TO COMPLETE THIS FORM --W e estimate that it w ill take yo u abo ut 3 minutes t o co mp lete this fo rm. This includ es the time it w ill take to read the instructio ns, gather the necessary facts and fill o ut the fo rm. SSA-3 2 8 8 I nternet (1 2 / 9 9 )

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