Form SSA-120 Application For Access to SSA Systems

Form SSA-120 (04-2019)
Discontinue Prior Editions
Social Security Administration

Page 1 of 4
OMB No. 0960-0791

APPLICATION FOR ACCESS TO SSA SYSTEMS
(TYPE OR PRINT CLEARLY- ALL ILLEGIBLE FORMS WILL BE RETURNED)
1. Applicant Information
2. Type of Request
SSA Employee
Non SSA Employee
(Please enter all previous issued PINS/TSO IDs)
2A. Create New
2B. Change Access/LOC/ORG
(Please specify) SEE INSTRUCTIONS
PIN
PIN
TSO ID
TSO ID
3A. Environment For Access (Check only one)

3B. ESEF only (Check all that apply)

Production
Integration
LAN Only
ESEF (Complete block 3B)
4. (PRINT) Last Name

ESEF TSO/BATCH
ESEF CICS TEST
ESEF CICS VALIDATION
First (Official)

MI

5. Social Security Number

7. SSA Component and Security Department or External Organization

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
12C. Title

12D. Telephone

12B. Requestor's Management Official's Signature
12E. Requestor's Mailing Address

12F. Date

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

14G. PIN/TSO ID

14I. PIN/TSO ID Expires:

15. If you have any questions, contact:

16. Access Denied
(Reason)

14H. Base Profile

14E. Date

Page 2 of 4

Form SSA-120 (04-2019)

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
Collection and Use of Personal Information
Section 205(a) of the Social Security Act, as amended, 5 U.S.C. § 552a(e)(10), and 44 U.S.C. § 3553 allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may affect your
ability to access the agency’s information technology systems and resources.
We will use the information to authorize access to the agency’s information technology systems. We may also share your
information for the following purposes, called routine uses:
• To notify another Federal agency when, or verify whether, a Personal Identity Verification card is no longer valid; and
• We may disclose information to appropriate Federal, State, and local agencies, entities, and persons when (1) we suspect or
confirm that the security or confidentiality of information in this system of records has been compromised;(2) we determine
that as a result of the suspected or confirmed compromise there is a risk of harm to economic or property interests, identity
theft or fraud, or harm to the security or integrity of this system or other systems or programs of Social Security Administration
(SSA) that rely upon the compromised information; and(3) we determine that disclosing the information to such agencies,
entities, and persons is necessary to assist in our efforts to respond to the suspected or confirmed compromise and prevent,
minimize, or remedy such harm. SSA will use this routine use to respond only to those incidents involving an unintentional
release of its records.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0214, entitled Personal
Identification Number File, as published in the Federal Register (FR) on September 8, 1994, at 59 FR 46439, and 60-0361,
entitled Identity Management System, as last published in the FR in full on November 3, 2006, at 71 FR 64751, and subsequently
modified on December 10, 2007, at 72 FR 69723. Additional information and a full listing of all our SORNs are available on our
website at www.ssa.gov/privacy/.
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 (OMB) control number. The OMB control number for this collection is 0960-0791. We estimate that it
will take about 2 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to
our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Page 3 of 4

Form SSA-120 (04-2019)

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

Applicant Information

For non-SSA employees please specify whether you are a contractor, DDS, Host
enrollee, Student, etc. See ISP Section: Access Control for additional details.

2.

Type of request

• 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).

3. A.

Environment for access

3. B.

SEF environment

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.

4.

Name

Print official name as in personnel records (no nicknames).

5.

Social Security Number

6.

Office/Branch Code

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.

7.

SSA Component and Security SSA Field employees should enter the name of their Field office and Security
Department. SSA non-field office employees should enter their component name
Department or External
and Security Department. All others enter the name of your employing company
Organization
or agency. Security Department example: Dept: DOISDSE.
Position Title
• 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.
Justification/Remarks
Use this space to justify access privileges needed. If your access is needed for a
specific project or domain provide the information.
Security Requirements and
Privacy Act Statement
Applicant’s Signature
After reading the Security Requirements and Privacy Act Statement in Block 10,
signature of person named in Block 4 should be provided.
Date
Enter date when signature provided in Block 11. A.
Telephone Number
Provide work telephone number including area code for the person in Block 11. A.
Requesting Management
A Division Director or higher-level official within the requesting component must
Official’s Name
approve and sign the form for personnel in central office components.
Requesting Management
Provide signature of person named in Block 12. A.
Official’s Signature
Title
Provide the title of the person named in Block 12. A.
Telephone Number
Provide work telephone number including area code for the person in Block 12. B.
Requesting Management
Provide mailing address of person named in Block 12. A.
Official’s Mailing Address
Date
Enter date when signature provided in Block 12. B.
Print Reviewing Security
Provide printed name of the Reviewing Security Official. If you are the security
Official’s Name CSO/CDSI
administrator granting or denying the access skip 13. A-F. Complete your
information in section 14 – 16.
Reviewing Security Official’s
Provide mailing address for person named in Block 13. A.
Mailing Address
Reviewing Security Official’s
Signature of person named in Block 13. A. should be entered in this block.
Signature
Date
Enter date when signature provided in Block 13. C.
Telephone Number
Provide work telephone number including area code for the person in Block 13. A.
Component/Region
Provide component/region for person named in Block 13. A.
Print Approving Official’s
Provide printed name of the security administrator granting or denying the access
Name
of applicant.

8.

9.
10.
11. A.
11. B.
11. C.
12. A.
12. B.
12. C.
12. D.
12. E.
12. F.
13. A.

13. B.
13. C.
13. D.
13. E.
13. F.
14. A.

Page 4 of 4

Form SSA-120 (04-2019)

INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR ACCESS TO SSA- SYSTEMS (SSA-120)
14. B.
14. C.
14. D.
14. E.
14. F.
14. G.
14. H.
14. I.
15.

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

16.

Access Denied

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.
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 Hearing Operations Regional and Field personnel - Send the form through the
Security Officer in the OHO 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: OSA Component Security Officer, 3G6D Perimeter East Building.
4. Other Central Office personnel – Send the form through the appropriate Component
Security Officer for processing.