Revised Form SSA-88

Form SSA-88 Form Approved

OMB #0960-0760

Pre-Approval Form For

Consent Based Social Security Number Verification (CBSV)

COMPANY REGISTRATION

1. Name of the Company

2. Company Address (P.O. Box alone is not acceptable)

Address Line 1 __________________________________________________

Address Line 2 __________________________________________________

City, State, Zip __________________________________________________

3. EIN (Employer Identification Number)

(Provide primary EIN if your company uses more than one.)

EMPLOYEE(S) AUTHORIZED TO USE CBSV

List the names of all employees unless your company will access CBSV solely through a web service platform. For the web service platform, provide corresponding information of the Responsible Company Official as the employee authorized to use CBSV.

4. Name of Employee(s) Authorized to Use CBSV:

5. Telephone Number of Employee(s) Authorized to Use CBSV:

(include area code)

6. Email Address of Employee(s) Authorized to Use CBSV:

AUTHORIZED SIGNATURE OF COMPANY MANAGER OR

AUTHORIZED REPRESENTATIVE

7. ______________________________________

Name of Company Manager or Authorized Representative (print or type)

______________________________________

Signature of Company Manager or Authorized Representative

______________________________________ _________________

Title Date

______________________________________

Telephone Number (include area code)

______________________________________

Email Address

See SSA’s CBSV User Guide for information regarding the extent and nature of employee’s authority to use CBSV.

Notify us if your authorized employee leaves your company or if you choose to revoke any or all of your employee's authorization to use SSA's Business Services Online (BSO).

Privacy Act Notice

The Social Security Administration (SSA) is allowed to collect the information on this form under Sections 205 and 1106 of the Social Security Act and the Privacy Act of 1974 (5 U.S.C. § 552a). We need this information to register your company and your authorized employee(s) to use our system for verifying Social Security Numbers and to contact you, if necessary. Giving us this information is voluntary. However, without the information we will not be able to provide this service to your company. SSA may also use the information we collect on this form for such purposes authorized by law, including to ensure the appropriate use of the service.

Paperwork Reduction Act Notice

This information collection meets the clearance requirements of 44 U.S.C. 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take you about 5 minutes to complete this form. You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Form SSA-88