Computer Information Development LLC 713 W. Duarte Rd. # 106 Arcadia, CA 91007 (Do Not Change or Modify This Line)
Privacy Act Statement
SSA is authorized to collect information on this form under Sections 205 and 1106 of the Social Security Act and the Privacy Act of 1974
(5 U.S.C. § 552a). We need this information to provide verification of your name and SSN to the Company and/or the Company's Agent
named on this form. Giving us this information is voluntary. However, we cannot honor your request to release this information without
your consent. SSA may also use the information we collect on this form for such purposes authorized by law, including to ensure the
Company and/or Company's Agent's appropriate use of the SSN verification service.
Paperwork Reduction Act Statement - This information collection meets 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. You may send comments on our time estimate to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.
Send to this address only comments relating to our time estimate, not the completed form.
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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
Security Services of CT, Inc.
25 Controls Drive, Shelton, CT 06484
VERI-TAX LLC 30 Executive Park, Suite 200 Irvine, CA 92614
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Do Not Change or Modify This Line
Do Not Change or Modify This Line
