Form SSA-120 Application For Access to SSA Systems

APPLICATION FOR ACCESS TO SSA SYSTEMS

(TYPE OR PRINT CLEARLY- ALL ILLEGIBLE FORMS WILL BE RETURNED)

1. APPLICANT INFORMATION

2. TYPE OF REQUEST (Please enter all previously issued PINS/TSO IDS)

NON SSA EMPLOYEE

SSA EMPLOYEE

2A.

CREATE NEW

2B.

CHANGE ACCESS/LOC/ORG

PIN

(Please specify) SEE INSTRUCTIONS

PIN
TSO ID

TSO ID
3A. ENVIRONMENT FOR ACCESS (Check only one)
PRODUCTION

3B. ESEF only (Check all that apply)
ESEF TSO/BATCH

INTEGRATION

ESEF CICS TEST

LAN ONLY

ESEF CICS VALIDATION

ESEF (Complete block 3B)
4. (PRINT) LAST NAME

FIRST (OFFICIAL)

MI

7. SSA COMPONENT NAME OR EXTERNAL ORGANIZATION NAME

5. SOCIAL SECURITY NUMBER

6. OFFICE/BRANCH CODE

8. POSITION TITLE (See Instructions)

9. JUSTIFICATION/REMARKS

10. I HAVE READ AND UNDERSTAND THE SECURITY REQUIREMENTS AND
PRIVACY ACT STATEMENT ON PAGE 2 OF THIS FORM.
11A. APPLICANT'S SIGNATURE

11B. DATE

See continuation sheet

11C. TELEPHONE

RESERVED FOR REQUESTOR’S MANAGEMENT AUTHORITY

12A. (PRINT) REQUESTOR’S MANAGEMENT OFFICIAL’S NAME

12B. REQUESTOR’S MANAGEMENT OFFICIAL’S SIGNATURE

12C. TITLE

12E. REQUESTOR’S MAILING ADDRESS

12D. TELEPHONE

RESERVED FOR REVIEWING SECURITY AUTHORITY

13A. (PRINT) REVIEWING SECURITY OFFICIAL’S NAME CDSI/CSO

13B. REVIEWING SECURITY OFFICIAL’S MAILING ADDRESS

13C. REVIEWING SECURITY OFFICIAL’S SIGNATURE
13D. DATE

13E. TELEPHONE

13F. COMPONENT/REGION

RESERVED FOR FINAL APPROVING AUTHORITY
14A. (PRINT) APPROVING OFFICIAL'S NAME

14B. APPROVING OFFICIAL’S SIGNATURE

14C. TITLE

14D. TELEPHONE

14F. DATE RECEIVED
14I. PIN/TSO ID EXPIRES:

16.

ACCESS DENIED

Form SSA-120 (05-2011)

14G. PIN/TSO ID

12F. DATE

14H. BASE PROFILE

15. IF YOU HAVE ANY QUESTIONS CONTACT:

(REASON)
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14E. DATE

SECURITY REQUIREMENTS FOR USERS OF
SSA'S COMPUTER SYSTEMS
You should be aware that your PIN/ID serves as your "electronic signature" on all systems transactions for which it is
used. This means that you will be held responsible if someone else uses it in connection with a systems transaction.
To monitor the users of SSA's computer systems for compliance with these requirements, SSA records all systems
transactions and conducts routine reviews for inappropriate or illegal activity.
A violation of any of the following security requirements could result in termination of systems access privileges and
serious disciplinary action, possibly removal. In addition, Public Law 98-473, Chapter 21 ("Counterfeit Access Device and
Computer Fraud and Abuse Act of 1984"), and Public Law 99-474 ("Computer Fraud and Abuse Act of 1986") provide
criminal penalties for any person accessing a Government-owned or operated computer illegally.
The information below will assist you in carrying out your responsibility in this area.
1. The PIN/ID you are assigned is for your use only. Lending it to someone else is a security violation and may result in
disciplinary action against both parties.
2. Never disclose your password. Do not put it in writing. Safeguard it. Your password is the key to one of SSA's most
valuable resources.
3. SSA's computer systems must be used only for work-related purposes which are consistent with the justification on
each user's approved request for systems access privileges. Never use the Agency's computers for activities
inconsistent with SSA's mission.
If you become aware of any violation of these requirements or suspect that your PIN/ID may have been used by
someone else, it is your responsibility to immediately report that information to your security officer.

PRIVACY ACT STATEMENT
As required by 5 USC 552a (The Privacy Act of 1974), you are advised that the Social Security Administration (SSA) is
authorized to collect that data required on this form by Executive Order 10450. Your response is not required by law.
However, if you do not provide this information, you will not be granted access to SSA's computer systems. SSA will use
the information in this form to limit access to computerbased SSA information resources. SSA will not make any
disclosure of this information to agencies or individuals outside this Department unless required by law or your written
consent accompanies the request.
The Social Security Number (SSN) is used as an identifier in the Federal Service because of the large number of present
and former Federal employees and applicants whose identity can only be distinguished by use of the SSN. Collection of
the SSN for a system of records is authorized by Executive Order 9397.

Form SSA-120 (05-2011)

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INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR ACCESS TO SSA- SYSTEMS (SSA-120)
1.

Applicant Information

2.

Type of request

3. A.

Environment for access

3. B.
4.
5.
6.

SEF environment
Name
Social Security Number
Office/Branch Code

7.

SSA component name or
external organization name

8.

Position Title

9.

Justification/Remarks

10.

Security Requirements and
Privacy Act Statement
Applicant’s Signature

11. A.
11. B.
11. C.
12. A.
12. B.
12. C.
12. D.
12. E.
12. F.
13. A.

Date
Telephone Number
Requesting Management
Official’s Name
Requesting Management
Official’s Signature
Title
Telephone Number
Requesting Management
Official’s Mailing Address
Date
Print Reviewing Security
Official’s Name CSO/CDSI

13. D.
13. E.
13. F.
14. A.

Reviewing Security Official’s
Mailing Address
Reviewing Security Official’s
Signature
Date
Telephone Number
Component/Region
Print Approving Official’s Name

14. B.
14. C.
14. D.
14. E.
14. F.
14. G.

Approving Official’s Signature
Title
Telephone Number
Date
Date Received
PIN/TSO ID

13. B.
13. C.

Form SSA-120 (05-2011)

For non-SSA employees, please specify whether you are a contractor, DDS, Host
enrollee, Student, etc. See ISSH Chapter 10 attachment “C” for additional details.
• If you do not have a PIN or TSO ID and need one assigned place an “X” in the
appropriate box(es).
• If you have a PIN/TSO ID but need your access privileges, location or organization
changed place an “X” in the appropriate box(es).
Place one “X” in the box to indicate what environment you require access to. If you are
applying for ESEF access complete box 3B. If you are not applying for ESEF
skip 3B.
Place an “X” in all applicable boxes for ESEF environment.
Print official name as in personnel records (no nicknames).
Provide the SSN of the person applying for PIN/TSO ID.
Provide the 3-digit office code if you are requesting a PIN. Provide the 3-digit branch
code if you are requested the creation of a TSO ID.
SSA Field employees should enter the name of their field office. SSA non-field office
employees should enter their component name. All others enter the name of your
employing company or agency.
• SSA employees – Enter your position title from your most recent SF-50, Notification
of Personnel Action. Claims representatives must also enter their specialty.
• Non SSA employees – Enter the title commonly used by your company or
organization for your position.
Use this space to justify access privileges needed. If your access is needed for a specific
project or domain provide the information.
After reading the Security Requirements and Privacy Act Statement in Block 10,
signature of person named in Block 4 should be provided.
Enter date when signature provided in Block 11 A.
Provide work telephone number including area code for the person in Block 11 A.
A Division Director or higher-level official within the requesting component must
approve and sign the form for personnel in central office components.
Provide signature of person named in Block 12 A.
Provide the title of the person named in Block 12 A.
Provide work telephone number including area code for the person in Block 12 B.
Provide mailing address of person named in Block 12 A.
Enter date when signature provided in Block 12 B.
Provide printed name of the Reviewing Security Official. If you are the security
administrator granting or denying the access skip 13 A-F. Complete your information
in section 14 – 16.
Provide mailing address for person named in Block 13 A.
Signature of person named in Block 13 A should be entered in this block.
Enter date when signature provided in Block 13 C.
Provide work telephone number including area code for the person in Block 13 A.
Provide component/region for person named in Block 13 A.
Provide printed name of the security administrator granting or denying the access of
applicant.
Signature of the person named in Block 14 A should be entered in this block.
Provide the title of the person named in Block 14 A.
Provide work telephone number including area code for the person in Block 14 A.
Enter date when signature provided in Block 14 B.
Enter date form was received by the person named in Block 14 A.
Enter the PIN/TSO ID created for the person named in Block 4.
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INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR ACCESS TO SSA- SYSTEMS (SSA-120)
14. H.
14. I.
15.

Base Profile
PIN/TSO ID
Questions

16.

Access Denied

Enter the profile given to the person named in Block 4.
Enter expires date for PIN/TSO ID expiration if applicable.
Enter the name and telephone number including the area code of the person to call if
there are any questions.
Enter the reason for denying the access for the person named in Block 4.

Disposition of the Completed Form
1. Regional, Field and DDS personnel - Send the form through the Local Security Officer to
the appropriate Security Specialist or Regional Security Officer.
2. Office of Hearings and Appeals Regional and Field personnel - Send the form through the
Security Officer in the OHA Regional Office to the Component Security Officer, 5107
Leesburg Pike, Falls Church, Virginia 22041-3255.
3. For access to the ESEF - Component Security Officer (CSO) should send the
signed/complete form to: OESAE Component Security Officer, 4-N-28 Operations
Building.
4. Other Central Office personnel - Send the form through the appropriate Component
Security Officer for processing.

Form SSA-120 (05-2011)

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