Fillable SSA Consent (Central Connecticut State University)

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SSA Consent (Central Connecticut State University)

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Social Security Administration
Form Approved
OMS
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:
Signature
I want this information released because I
am
conducting the following business transaction:
Employment
Background
Screening
Reason (s) for using CBSV: (Please select all that apply)
o Mortgage Service 0 Banking Service
[g]
Background Check 0 License Requirement
o Credit Check 0 Other
with the following company ("the Company"):
Company Name:
Securi
ty
Services
of
CT,
Inc.
(SSC,
Inc.)
Company Address:
25
Controls
Drive,
Shelton,
CT
06484
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:
Computer
Information
Development
LLC
713
West
Duarte
Road
#106,
Arcadia,
CA,
91007
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.)
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
Form SSA-89 (06-2013)
Privacy
Act
Statement
SSA
is
authorized to collect the 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 the
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 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 0 FF _
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
Form SSA-89 (06-2013)
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SSA Consent (Central Connecticut State University)

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Completed 22 July 2020

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