Form SSA-89 Authorization for SSA to Release SSN Verification

Form SSA 89 Form Approved

Form Approved

OMB #0960-_____

Social Security Administration

Authorization for the Social Security Administration (SSA)

To Release

Social Security Number (SSN) Verification

Printed Name ____________________Date of Birth______________SSN ___________

I am conducting the following business transaction

____________________________________________________________________________

[Identify a specific purpose. Example—seeking a mortgage from the Company– “identity verification” or “identity proof or confirmation” is not acceptable.].

with the following company (“the Company”):

Company Name Address

I authorize the Social Security Administration to verify my name and SSN to the Company and/or the Company’s Agent, if applicable, for the purpose I identified.

The name and address of the Company’s Agent is:

_____________________________________________________________________________

I am the individual to whom the Social Security number was issued or that person’s legal guardian. I declare and affirm under the penalty of perjury that the information contained herein is true and correct. I acknowledge that if I make any representation that I know is false to obtain information from Social Security records, I could be found guilty of a misdemeanor and fined up to $5,000.

Signature __________________________________ Date Signed ___________________

This consent is valid only for 90 days from the date signed, unless indicated otherwise by the individual named above.

Contact information of individual signing authorization:

Address ______________________________________________

City/State/Zip ______________________________________________

Phone Number ______________________________________________

Form SSA-89

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 3 minutes to complete the form. You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send to this address only comments relating to our time estimate, not the completed form.

………………………………………………TEAR OFF ………………………………

NOTICE TO NUMBER HOLDER

The Company and/or its Agent have entered into an agreement with SSA that, among other things, includes restrictions on the further use and disclosure of SSA’s verification of your SSN. To view a copy of the entire model agreement, visit www.ssa.gov/bso/cbsvInstructions.html