ssa-3288

Form SSA-3288 (02-2023) UF Consent for Release of Information You must complete all required fields. We will not honor your request unless all required fields are completed. (*Signifies a required field. **These are not mandatory fields for the consent form to be acceptable. Please complete these fields in case we need to contact you about the consent form TO: Social Security Administration

Full Name*

Date of Birth MMDDYYYY*

Date

Full Social Security Number*

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

*NAME OF PERSON OR ORGANIZATION:

Dax J. Lonetto, Sr., PLLC

*ADDRESS OF PERSON OR ORGANIZATION: PHONE NUMBER OF PERSON OR ORGANIZATION:

18715 N. Dale Mabry Hwy. Lutz, Florida 33548

813-609-5500

*I want this information released because: We may charge a fee to release information for non-program purposes.

For My Social Security Claim (Title II or Title XVI)

*Please release the following information selected from the list below: Check at least one box. If requesting medical records, do not check both boxes 7 and 8. We will not disclose records unless you include specific date ranges where applicable.

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 § 1746) that | 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 seeks or obtains access to records about another person under false pretenses is punishable by a fine of up to $5,000.

Signature*

Date*

Date

Address*

Number Street, City, State, Zip Code

Daytime Phone*

Relationship if not the subject of the record

Daytime Phone