SSA-89 Authorization for the Social Security Administration (SS

Form SSA-89 (04-2025)
Discontinue Prior Editions
Social Security Administration

Page 1 of 1
OMB No.0960-0760

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

Date of Birth:

Social Security Number:

Reason for authorizing consent: (Please select one)
To apply for a mortgage

To apply for a loan

To meet a licensing requirement

To open a bank account

To open a retirement account

Other

To apply for a credit card

To apply for a job

With the following company ("the Company"):
Company Name:
Company Address:
The name and address of the Company's Agent (if applicable):
Agent's Name:
Agent's Address:
I authorize the Social Security Administration to verify my SSN (to match my name, SSN, and date of birth with information in SSA
records and provide the results of the match) to the Company or Company's Agent, if applicable, for the purpose I identified. I also
authorize SSA to disclose the basis for a no-match to the Company and/or Company Agent, when it is a Permitted Entity as
defined by section 215 of the Economic Growth, Regulatory Relief, and Consumer Protection Act. I am the individual to whom the
SSN was issued or the parent or legal guardian of a minor or 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 one-time use. 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.

Signature:

(Please initial.)
Date Signed:

Relationship (if not the individual to whom the SSN was issued):
Privacy Act Statement Collection and Use of Personal Information Sections 205(a) and 1106 of the Social Security Act, as
amended, allow us to collect this information, which we will use to verify your Social Security Number to a company or company's
agent. Providing this information is voluntary, but not providing such may prevent us from assisting you with the request. As law
permits, we may use and share the information you submit, including with other Federal agencies, contractors, and others, as
outlined in the routine uses within System of Records Notice 60-0058, available at www.ssa.gov/privacy. The information you
submit may also be used in computer matching programs for Federal benefits eligibility and to recoup debts under these
programs.
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. We estimate that it will take about 20 minutes to read the instructions, gather
the facts, and answer the questions. Send only comments regarding this burden estimate or any other aspect of this
collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. .

-------------------------------------------------------------------------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.