BPQY - SSA-3288 (TTW)

Social Security Administration Consent for Release of Information

Form Approved 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. **Please complete these fields in case we need to contact you about the consent form TO: Social Security Administration

My Full Name*

First Name Middle Name Last Name

My Date of Birth (MM/DD/YYYY)*

Date

My Social Security Number*

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

*NAME OF PERSON OR ORGANIZATION:

*ADDRESS OF PERSON OR ORGANIZATION:

Idela T. Hernandez, CPWIC (IAS, LLC) Employment Network Service Provider

3050 Horseshoe Dr North, Suite 158 Naples, FL 34104

(American Dream Employment Network affiliate)

*I want this information released because: For benefits and work incentive advisement and counseling. We may charge a fee to release information for non-program purposes. Please send Benefits Planning Query to support employment services to be provided to person

named above by the American Dream Employment Network, an approved (Ticket to Work) SSA EN. *Please release the following information selected from the list below: Check at least one box. We will not disclose records unless you include date ranges where applicable.

My Medicare entitlement from date

Medical records from my claims folder(s) from date

activity and earnings. All employment supports data on SSA's record.

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(d2004) that I have examined all the information on this form and it is true and correct to the best of my knowledge. I understand that anyone who knowingly or willfully seeking or obtaining 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*

Date

*Address*

Full address as it is listed in your SSA records

Daytime Phone*

Relationship (if not the subject record)

If the Beneficiary signed above, write in this line SELF If the Rep Payee signed above, write in this line Rep Payee

Daytime Phone*

If the Rep Payee signed above, then enter here the Rep Payee's phone Number - Other than that leave it blank.

Witnesses 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

mustsignthisform ONLY if the above

signatureismarkIfmark by (Xsigned by