The Dallas CDPS Center for Disability and Programs Support will again review the consent
form and notify the requester (the attorney or record service) of any problems.
If there are no problems, CDPS Center for Disability and Programs Support will review
the photocopy against the original file for completeness and disclosure provisions
(e.g., child's claim, spouse's SSNs, etc.).
CDPS Center for Disability and Programs Support will prepare the certification form
SSA-473, and ensure that the ribbon and seal on the SSA-473 are prepared for the custodian's
After the certification is signed, CDPS Center for Disability and Programs Support
will prepare the cover letter, and the bill on Form SSA-1723.
CDPS Center for Disability and Programs Support will send the certification and the
bill to the requester (unless the DO specifies otherwise) and return the folder to
the DO, PSC, etc., as requested.
REQUEST FOR CERTIFICATION
TO: Social Security Administration Date:____/____/____
Center for Disability, Room 670
ATTN: Certification Request
1301 Young Street.
Dallas, TX 75202-5433
Please certify the photocopies of the attached file. Also attached are a copy of the
request and the signed consent form that meets the requirements in GN 03305.001 (if applicable).
If you have any questions, please contact ____________________________
at phone number: (_____)_____-_____ Office: ____________________
• Number Holder's Name_____________ SSN____________________
• Has earnings data been removed from the file? Yes___ No___
(Earnings information (e.g., SEQYs) are IRS documents; the RO is not permitted to
certify IRS documents. SSA-7050s are used to certify earnings information; see GN 03360.025D)
• Does the file pertain to more than one beneficiary/recipient?
(Remove and "sanitize" or obtain a second consent)
• Hours Spent to Photocopy _______________________
• Rate of Pay of employee doing the photocopying ______________
• Number of Pages Photocopied __________________
(Tip: Record the number of pages from the counter on the photocopier.)
• Record Service or Attorney's office made the photocopy
• Record Service or Attorney's office used their paper
The file should be returned to the DO ____________ Attention:_____________
The file should be returned to the PSC, Wilkes-Barre, etc. ______________
NOTE: The records and bill will be mailed to the requester (attorney, record service,
etc.) by the Dallas CDPS Center for Disability and Programs Support unless otherwise
indicated. The Office of Finance in Central Office will follow-up on unpaid bills.)