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Templates
Government forms
Form SSA 4111 - May 2019

Government forms

Form SSA 4111 - May 2019

Certificate of Election for Reduced Widow(er)'s and Surviving Divorced Spouse's Benefits

Authorization to Disclose Information to the Social Security Administration (SSA)

Originally published by: ssa.gov

Used 23 times

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Large thumbnail of Form SSA 4111 - May 2019

Large thumbnail of Form SSA 4111 - May 2019

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Frequently asked questions

The SSA 4111 form is used to authorize a third party to disclose information to the Social Security Administration (SSA). This form is necessary to allow the SSA to obtain information from third parties that is needed to make a determination on an individual's claim for benefits.
Individuals who want to authorize a third party to disclose information to the Social Security Administration (SSA)
The completed form should be submitted to the Social Security Administration (SSA).

Used 23 times