UBPAO Form 004, 09/05/08

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: Date of Birth:

Social Security No.:

I authorize the Social Security Administration to release information or records about me to:
Name: Rehab Services, Inc. Phone: (701) 478-9122

Address: 3350 35th Avenue South, Fargo, ND 58104

Street City State ZIP

Fax Number: (701) 478-9123 E-Mail Address: ndbenefits@hotmail.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: Date:

UBPAO Form 004, 09/05/08

Representative Payee’s Signature: Date: