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SSA Form

Social Security Administration

Please fill out the required fields below and click submit when finished. 

Social Security Administration

Form Approved

 

Consent for Release of Information

 

OMB No. 0960-0566

 

 

You must complete all required fields. We will not honor your request unless all required fields are completed. (*signifies a required field).

 

TO: Social Security Administration

 

                                                                                                       

*My Full Name

 

My Date of Birth

 

My Social Security Number

 

 

(MM/DD/YYYY)

 

 

I authorize the Social Security Administration to release information or records about me to:

 

 *NAME OF PERSON OR ORGANIZATION:

 

Disabled Workers LLC

 *ADDRESS OF PERSON OR ORGANIZATION:

 2715 Terrace Dr. Cedar Falls, IA 50613

 

 *I want this information released because:

We may charge a fee to release information for non-program purposes.

 

 To be used to assist in Social Security work incentive benefit analysis.

 

 *Please release the following information selected from the list below:

 

You must specify the records you are requesting by checking at least one box. We will not honor a request for "any and all records" or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested.

 

  1. Social Security Number

 

  1. Current monthly Social Security benefit amount

 

  1. Current monthly Supplemental Security Income payment amount

 

 

4.

My benefit or payment amounts from date

 

 

to date

 

 

5.

My Medicare entitlement from date

 

 

to date

 

 

 

 

6.

Medical records from my claims folder(s) from date

 

 

 

 

to date

 

 

 

 

 

If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social Security office.

 

  1. Complete medical records from my claims folder(s)

 

  1. Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application, determination or questionnaire)

 

             BPQY, Monthly Earnings Statement

 

I am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or the legal guardian of a legally incompetent adult. I declare under penalty of perjury (28 CFR § 16.41(d)(2004)) that I have examined all the information on this form, and any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly or willfully seeks or obtain access to records about another person under false pretenses is punishable by a fine of up to $5,000. I also understand that I must pay all applicable fees for requesting information for a non-program-related purpose.

 

Please draw your signature in the box below using either your mouse or finger if you have a touchscreen.
By signing your name below you attest that this is your legal signature.

*Signature:

clear

*Date:

 

*Address:

Relationship (if not the subject of the record):

*Daytime Phone:     

 

Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the signature line above.

1.Signature of witness

2.Signature of witness

N/A

N/A

 

 

Address(Number and street,City,State, and Zip Code)

Address(Number and street,City,State, and Zip Code)

 

 

Form SSA-3288 (07-2013) EF (07-2013)

 

 

 

 

Social Security Administration

Form Approved

 

Consent for Release of Information

 

OMB No. 0960-0566

 

 

You must complete all required fields. We will not honor your request unless all required fields are completed. (*signifies a required field).

 

TO: Social Security Administration

 

*My Full Name

 

My Date of Birth

 

My Social Security Number

 

 

(MM/DD/YYYY)

 

 

I authorize the Social Security Administration to release information or records about me to:

 *NAME OF PERSON OR ORGANIZATION:

 

Disabled Workers LLC

 *ADDRESS OF PERSON OR ORGANIZATION:

 2715 Terrace Dr. Cedar Falls, IA 50613

 

 *I want this information released because:

We may charge a fee to release information for non-program purposes.

 

 To be used to assist in Social Security work incentive benefit analysis.

 

 *Please release the following information selected from the list below:

 

You must specify the records you are requesting by checking at least one box. We will not honor a request for "any and all records" or "my entire file." Also, we will not disclose records unless you include the applicable date ranges where requested.

 

  1.      Social Security Number

 

  1.     Current monthly Social Security benefit amount

 

  1.     Current monthly Supplemental Security Income payment amount

 

 

4.

My benefit or payment amounts from date

 

 

to date

 

 

5.

My Medicare entitlement from date

 

 

to date

 

 

 

 

6.

Medical records from my claims folder(s) from date

 

 

 

 

to date

 

 

 

 

 

If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social Security office.

 

  1.      Complete medical records from my claims folder(s)

 

  1.              Other record(s) from my file (you must specify the records you are requesting, e.g., doctor report, application, determination or questionnaire)

 

                    Non-Certified yearly total of earnings

 

 

 

 

I am the individual, to whom the requested information or record applies, or the parent or legal guardian of a minor, or the legal guardian of a legally incompetent adult. I declare under penalty of perjury (28 CFR § 16.41(d)(2004)) that I have examined all the information on this form, and any accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly or willfully seeks or obtain access to records about another person under false pretenses is punishable by a fine of up to $5,000. I also understand that I must pay all applicable fees for requesting information for a non-program-related purpose.

 

*Signature:

*Date:

 

*Address:

Relationship (if not the subject of the record):

*Daytime Phone:     

 

Witnesses must sign this form ONLY if the above signature is by mark (X). If signed by mark (X), two witnesses to the signing who know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the signature line above.

1.Signature of witness

2.Signature of witness

N/A

N/A

 

 

Address(Number and street,City,State, and Zip Code)

Address(Number and street,City,State, and Zip Code)

 

 

Form SSA-3288 (07-2013) EF (07-2013)

 

 

 


Company

Home Office:

DisABLEd Workers
2715 Terrace Dr
Cedar Falls, IA 50613

Toll Free: 1 877-291-9806
Phone: 319-215-4543
Fax: 888-504-7957

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