Form SSA-89 Authorization for SSA to Release SSN Verification

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 (8/15/2008)

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 read the instructions, gather the facts, and answer the questions. SEND OR
Please
see
revisedSOCIAL SECURITY
BRING THE COMPLETED FORM TO
YOUR
LOCAL
PRA
statement
OFFICE. You can find your local Social
Security
office through SSA’s website at
below.
www.socialsecurity.gov. Offices are also
listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800325-0778). 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.
Privacy Act Statement - Section 205 of the Social Security Act authorizes SSA to collect
the information on this form and provide the verification of your SSN to the requesting
party based on your consent. Your response is voluntary; however, without the
information on this form and your consent, we will not be able to provide the
verification of your SSN to the requesting party. We will only release the verification of
your SSN from our records and only to the person(s) or organization(s) you authorize to
receive that information. If you have any questions about this form, you may contact
your local Social Security office.
………………………………………………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
\

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.