SSA-8510 – Title II and Title XVI general evidence (MSSICS version)

MSSICS
SSS-SS-SSSS

PERSONAL INFORMATION AUTHORIZATION
SSSSS SSSSSSSSSS

APIA
TRANSFER TO: XXXX

PERSON AVAILABLE TO PROVIDE RESPONSE (Y/N): X
AUTHORIZATION FOR DISCLOSURE OF PERSONAL INFORMATION TO SSA (Y/N): X
NAME OF PERSON PROVIDING RESPONSE:
XXXXXXXXXXXXXXX XXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXX XXXX
RELATIONSHIP OF PERSON PROVIDING RESPONSE: 9

1=SELF
2=PARENT OF MINOR CHILD
3=LEGAL GUARDIAN

DATE RESPONSE PROVIDED (MMDDYY): 999999
ADD AUTHORIZATION RESPONSE (Y): X

REMARKS (Y): X