Form SSA-89 Authroiztion for the Social Security Administration to R

Form Approved
OMB No. 0960-0760

Social Security Administration

Authorization for the Social Security Administration (SSA) To Release Social
Security Number (SSN) Verification
Printed Name:

Date of Birth:

Social Security Number:

I want this information released because I am conducting the following business transaction:

Reason (s) for using CBSV: (Please select all that apply)
Mortgage Service

Banking Service

Background Check
Credit Check

License Requirement
Other

with the following company ("the Company"):
Company Name:
Company 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 the parent or legal guardian of
a minor, or the legal guardian of a legally incompetent adult. 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
Signature

days from the date signed.
Date Signed

Relationship (if not the individual to whom the SSN was issued):
Contact information of individual signing authorization:
Address
City/State/Zip
Phone Number
Form SSA-89 (06-2013)

(Please initial.)

Privacy Act Statement
SSA is authorized 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 provide the
verification of your name and SSN to the Company and/or the Company's Agent named on this form.
Giving us this information is voluntary. However, we cannot honor your request to release this
information without your consent. SSA may also use the information we collect on this form for such
purposes authorized by law, including to ensure the Company and/or Company's Agent's appropriate
use of the SSN verification service.
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/cbsv/docs/SampleUserAgreement.pdf

Form SSA-89 (06-2013)