Completing Form SSA-89

Consent-Based Social Security Number Verification Service (CBSV)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0960-0760 can be found here:

Documents and Forms

Document Name Document Type
SSA-89 - New PA Statement.pdf Other-Revised PA Statement
SSA-89 Authroiztion for the Social Security Administration to R SSA-89 - Revised.pdf Form
SSA-89 - Current.pdf SSA-89 - Current IC Document

Information Collection (IC) Details

IC Title:	Completing Form SSA-89	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 401.100

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Revised PA Statement			SSA-89 - New PA Statement.pdf		Yes	No	Fillable Printable
Form	SSA-89	Authroiztion for the Social Security Administration to Release SSN Verification	SSA-89 - Revised.pdf		Yes	No	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,800,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,800,000	100,000	2,700,000
Annual IC Time Burden (Hours)	140,000	-62,500	202,500
Annual IC Cost Burden (Dollars)	3,920,000	3,920,000	0

Documents for IC

Title	Document	Date Uploaded
SSA-89 - Current	SSA-89 - Current.pdf	10/18/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.