If the applicant gives SSA permission to contact the third party listed in Part G
for additional information regarding the PASS, complete page 8 with a wet signature
or attestation, using the procedures outlined below.
A wet signature from the applicant is required on the top portion of page 9 in order
for SSA to release information regarding the PASS to the third party listed in Part
G or to the third party listed at the top of page 9. Such information may include
a copy of SSA’s decision or information about the applicant’s benefits related to
the PASS, but excludes medical records and tax return information.
The applicant must complete the bottom of page 9 for any public or private custodian
of records to disclose to SSA any non-medical records or information about the applicant.
If a custodian of records asks for a copy of the individual’s consent to allow disclosure
of the records to SSA, do not send the full PASS, rather only send a copy of the bottom
of page 9 to the custodian. The top of page 9 must also be redacted before sending
to avoid improper disclosure. The PASS Specialist should not send PII outside of the
agency using email.
The applicant must sign and date on page 10. Alternatively, the individual may attest
the application using the procedures outlined below. If the individual has a representative
payee, the payee must also sign or attest the application.
The individual can use attestation as a form of signature for the SSA-545-BK on pages
8 and 10, as well as the bottom portion of page 9, by following the procedures below:
Perform the attestation procedures identified in Alternative Signature Methods – GN 00201.015F, including all “Interviewer responsibilities” described in this section. Follow the
script for in-person interviews in accordance with GN 00201.015F.2, with the individual or the representative payee. For telephone interviews, follow
the script in accordance with GN 00201.015F.3.
Use the Document Processing System (DPS) to generate the attestation cover letter.
Select “Print and Send to ORS” button to ensure the document for attestation is in
the Online Retrieval System (ORS).
Give or mail the individual the attestation cover notice and a copy of the SSA-545-BK
with the Privacy Act Statement and Part J, Receipt; and
Fax a copy of the DPS attestation cover notice and the SSA-545-BK into eView (NDRed
if eView does not exist).
NOTE: On page 10 of Part I, there is a place for the applicant to include an email address.
It is the responsibility of the PASS Specialist to inform the individual that they
should not send personal identifying information (PII) via email. Likewise, the PASS
Specialist should not send any PII to individuals outside SSA using email.