Government to Government Services Online Website Account Modification/Deletion Form SSA-119

Guidelines for Completing the

Government to Government Services Online Account Modification/Deletion Form

REQUEST INFORMATION
Date of Request	Enter the date that the request is sent to the eData Administrator.
Type of Request	Enter Account Modification or Account Deletion. Note: Deletion requests for organizational shared accounts will delete the entire account where no one on that account will have access to the website.
Rationale:	State why this request is being made.
MODIFICATION REQUEST
Select the utilities to which the user will need to access	If this request is for an Account Modification, identify which utilities the user(s) will require access.
	Select the functions below that apply to every user on this account. Select all of the utilities that apply: B – State government agencies sending Birth records to SSA. BL – Federal/State government agencies sending Black Lung records to SSA. D – State government agencies sending Death records to SSA. DE – This user will exchange files via the Data Exchange application. FF – FBI, State government and law enforcement agencies send Fugitive Felon warrant information to SSA. IAR – State government agencies sending Interim Assistance Reimbursement files to SSA. OCSE – Federal government agencies sending New Hire, Quarterly Wage, and Federal Parent Locator System data to SSA for OCSE. Prisons – A Prison representative notifying SSA of incoming prisoners. SM – Secure Messaging users that require encryption of sensitive email messages. SW – Sheltered Workshops send payroll information to SSA Field Offices (FO). DD – Financial institutions submitting Direct Deposit information. OTHER – Select this item for a newly established utility not yet displayed on the registration form. Annotate the utility name in the Comments field.
Comments	Provide any comments, if desired. This field may also be used to identify a newly implemented utility for registration if not listed in the “Select Utilities field”.
USER ACCOUNT INFORMATION
User Name	Enter the user’s full name. If this request is for an organizational shared account, enter the main contact’s full name.
Organization Name	Enter the name of the organization affiliation, if any. If this request is for an organizational account, the organization name is mandatory.
Organization ID	Unique identifier required for all Data Reporting applicants (Birth/Death, Black Lung, Fugitive Felon, IAR, New Hire/Quarterly Wage, Prison, etc.) This identifier is used within the account grouping format.
Email Address	Enter the user’s email address
Phone	Enter the user’s phone number,
SPONSOR INFORMATION
Sponsor Name	Enter the Sponsor contact’s full name.
Phone	Enter the Sponsor’s phone number. Include the area code.
Office	Enter the Sponsor’s office designation.
ACCOUNT STATUS – Completed by eData Administrator
Status	Indicates the status of the account modification/deletion request: Request Submitted or Request Processed.
Completion Date	Defines when the account modification/deletion was processed.
Processed By	The name of the eData Administrator that processed this request.
Phone	The phone number of the eData Administrator that processed this request.
Comments	eData Administrator comments or suggestions for the Sponsor.
Once the Sponsor completes the information above, forward the form in WORD format to: [email protected]

05/07