Fillable Authorization For The Social Security Administration To Release Social Security Number (SSN) Verific

Fill Online, Printable, Fillable, Blank Authorization For The Social Security Administration To Release Social Security Number (SSN) Verific Form

Use Fill to complete blank online SOCIAL SECURITY ADMINISTRATION (MD) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Authorization For The Social Security Administration To Release Social Security Number (SSN) Verific

On average this form takes 5 minutes to complete

The Authorization For The Social Security Administration To Release Social Security Number (SSN) Verific form is 2 pages long and contains:

  • 0 signatures
  • 6 check-boxes
  • 16 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Social Security Administration

BROWSE SOCIAL SECURITY ADMINISTRATION (MD) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Form SSA-89 (02-2018)
Discontinue Previous Editions
Social Security Administration
Page 1 of 2
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:
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
Background Check
Credit Check
Banking Service
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 days from the date signed. (Please initial.)
Signature: 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:
Privacy Act Statement
Collection and Use of Personal Information
Form SSA-89 (02-2018)
Page 2 of 2
Sections 205(a) and 1106 of the Social Security Act, as amended, allow us to collect this information.
Furnishing us this information is voluntary. However, failing to provide all or part of the information may
prevent us from releasing information to a designated company or company’s agent.
We will use the information to verify your name and Social Security number (SSN). 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 routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0058, entitled
Master Files of SSN Holders and SSN Applications. Additional information and a full listing of all our SORNs
are available on our website at www.socialsecurity.gov/foia/bluebook.
-
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.
Paperwork Reduction Act Statement
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Authorization For The Social Security Administration To Release Social Security Number (SSN) Verific

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document