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 via facsimile or postal correspondence, to:

I want this information released because:

I need to have accurate and current information about my benefits to learn how these benefits would be affected by work. This will allow me to make informed decisions about working. Please send me a Benefits Planning Query (BPQY).

Please release the following information:

_____ Social Security Number

_____ Identifying information (includes date and place of birth, parents’ names)

__X__ Monthly Social Security benefit amount

__X__ 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)__________________________________________

__x__ Other (specify): See below.

Cash: Type of Benefit(s), current payment status, statutory blindness, date of disability onset, date of entitlement, Gross & net amount of benefits, others paid on the record, total family cash benefit, overpayment balance, monthly amount withheld.

Medical Reviews: Next medical review, medical re-exam cycle

Representation: Representative payee, authorized representative

Health Insurance: Type of Medicare (part A, part B, part C/D), start date, stop date, buy-in or subsidy, Medicaid eligibility, start date, stop date, buy-in or subsidy.

Title XVI (SSI) Work Exclusion: Blind work expenses, impairment-related work expenses, student earned income exclusions, pass exclusion, SSI earnings.

Title II (SSDI) Work Exclusion: Trial work months, start date, end date, number of months used, month of cessation, current SGA level.

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: ______________________________