UBPAO Form 004, 09/08/08

SOCIAL SECURITY INFORMATION RELEASE FORM
This release automatically expires one year from the date of signing, unless renewed, and can be revoked in writing at any time.

Name: Social Security No.:

Date of Birth:

I authorize the Social Security Administration to release information or records about me to:
Name: Address: Fax Number:
Street

Terry Peterson 112 2nd Ave SW

Phone:
City

701-839-4240
State

Minot E-Mail Address:

ND

58701

ZIP

701-838-2621

rsi5@srt.com

I want this information released because: I need this information for benefits planning. I authorize
release of a complete Benefits Planning Query (BPQY.) _X_ Monthly Social Security benefit amount _X_ Monthly Supplemental Security Income payment amount _X_ Record(s) from my file (specify) • My Cash Benefits (including type, status, statutory blindness indicator, date of onset, date of entitlement, full amount, net amount, whether others are paid on this record, the total family cash benefit, overpayment balance, and monthly amount withheld), • Health Insurance (including dates of hospital, medical, Advantage Plan and/or prescription drug coverage, state premium buy-in information, Part D subsidy information, and Medicaid information), • Medical Review (including date of next review and re-exam cycle), • Representation (whether I have a representative payee or authorized representative), • SSDI Work Activity (SGA amount, trial work months and month of cessation, if any), • SSI Work Exclusions (blind work expenses, impairment-related work expenses, student earned income exclusions, and PASS exclusion.) __X_ Other (specify): All employment supports data on Social Security’s records, Medicare premium amounts.
The Social Security employee providing the BPQY:

Additional Information Requested:
What are the primary and secondary disability codes on record for the Beneficiary?______________________ Is the Beneficiary in 1619 (b) status? ____________ Is the Beneficiary eligible for a Ticket to Work? ___________ If so, is the Ticket assigned? ___________ If yes, to whom is the Ticket assigned? ____________________________________________ Other:
______________________________________________________________________________________________________

I am the individual to whom the information/record applies or that person’s parent (if a minor) or legal guardian. I know that if I make any representation which I know is false to obtain information from Social Security records, I could be punished by a fine or imprisonment or both.

Claimant’s Signature: Representative Payee’s Signature:

Date: Date:

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