REQUEST FORM FOR COMMERCIAL ENTITIES
Date:
Business Name:
Requestor’s Name (must be an authorized officer or agent):
Business Street Address:
Mailing Address:
Business Telephone Number:
Statement of Specific Purpose for which Social Security number is needed and how the information will be used
by requestor: (check one)
[ ] Verification of the accuracy of personal information received by an entity in the normal course of business.
[ ] Use in a civil, criminal, or administrative hearing.
[ ] Insurance purposes.
[ ] Use in law enforcement and/or investigation of crimes.
[ ] Matching, verifying, or retrieving information.
[ ] Research activities.
[ ] Other. Please explain:
I, the undersigned, agree that I am an authorized officer and/or agent of the above named entity and have
requested social security number(s) for a purpose authorized under Florida law. I further agree that the above-
stated purpose is true and accurate. Under penalties of perjury, I declare that I have read the foregoing
[document] and that the facts stated in it are true.
Signature
For Office Use Only
Date Request Received
Date Request Completed
Clerk Processing Request
Any person who makes a false representation in order to obtain a social security number pursuant to
CS/HB 1673, commits a felony of the third degree, punishable as provided in s. 775.082 or s.
775.83,F.S.
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signature
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