Revised Form SSA-89

Form SSA-89

Form Approved

OMB #0960-0760

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.

This consent is valid only for 90 days from the date signed, unless indicated otherwise by the individual named above. If you wish to change this timeframe, fill in the following:

This consent is valid for _______ days from the date signed. _______ (Please initial.)

Signature __________________________________ Date Signed ___________________

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 http://www.ssa.gov/bso/cbsvPDF/agreement.pdf