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AUTHORIZATION FOR THE SOCIAL SECURITY ADMINISTRATION (SSA) TO OBTAIN WAGE AND EMPLOYMENT INFORMATION FOR:

{applicantNameCaps} RESIDING AT {clmntResAddrCaps}

On {subTsDate_en} you authorized us to get wage and employment information from payroll data providers used by your employer(s). The authorization you gave us is related to your . This document gives you information about your authorization.

We may use the information we receive from payroll data providers (as defined in section 1184 of the Social Security Act) to help us determine and for the additional purposes described below. The authorization you gave us remains in effect until: (1) your application(s) is denied in a final decision and no other claims or appeals are pending; (2) your ends and no other claims or appeals are pending; (3) you revoke your authorization in writing.

By authorizing SSA to obtain wage and employment information:

  • You or the client will not be subject to certain penalties under section 1129A of the Social Security Act if we are receiving your or the client's wage and employment information from a payroll data provider If you later revoke your authorization, you or the client will no longer be entitled to this protection.
  • You or the client are still responsible for making sure that your or the client's wages and employment information are reported accurately to us.
  • You or the client may have to pay us back if we pay you or the client too much because the payroll data provider(s) gave us incorrect wage or employment information.
  • If we get wage and employment information from payroll data providers based on this authorization, we may use the information for other purposes. For example, SSA may use your or the client's information to decide whether you or the client can get benefits under both the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) programs, even if your authorization was given for only one of those programs. We explain more about how SSA may use and disclose your or the client's wage and employment information in the Privacy Act Statement below.

I, {applicantNameCaps}, have authorized any payroll data providers to disclose any wage and employment information about me to the Social Security Administration.

I understand that anyone who knowingly lies or misrepresents the truth or arranges for someone to knowingly lie or misrepresent the truth is committing a crime which can be punished under Federal law, State law, or both. Everything in this document is true and correct to the best of my knowledge.

PRIVACY ACT STATEMENT
COLLECTION AND USE OF INFORMATION ON YOUR AUTHORIZATION

Sections 205(a), 225, 1184, and 1631(e) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent us from making an accurate and timely decision regarding your Social Security benefits.

We will use the information you provide to obtain information about you from payroll data providers. We will use the payroll data provider information to administer the Social Security Act, such as determining your eligibility for Social Security benefits. We may also share your information for the following purposes, called routine uses:

  1. To contractors and other Federal agencies as necessary, for the purpose of assisting the Social Security Administration (SSA) in the efficient administration of its programs. We contemplate disclosing information under this routine use only in situations in which SSA may enter a contractual or similar agreement with a third party to assist in accomplishing an agency function.
  2. To employers or former employers for correcting or reconstructing earnings records and for Social Security tax purposes only.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0089, entitled Claims Folders Systems and 60-0090, entitled Master Beneficiary Record. Additional information and a full listing of all our SORNs are available on our website at https://www.ssa.gov/privacy/sorn.html

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