SSA-200 (12-2010)
Destroy Prior Editions
Social Security Administration
CBSV Enrollment Application
Form Approved
OMB No. 0960-0760
PLEASE TYPE IN THE NECESSARY INFORMATION
DATE:
1. Company Identifying Information:
Company Name:
DBA (Doing Business As) Name:
Mailing Address:
City: State: Zip:
Company Email:
EIN:
Telephone:
2. Company Official:
Responsible Company Official: Telephone(s):
Contact Person(s):
Email Addresses:
3. Reason (s) for Using CBSV: (select all that apply (x))
Mortgage Service
Banking Service Credit Check Background Check
Licensing Requirement Other (Specify):
4. CBSV Usage Information:
Estimated Annual Volume of Requests:
Date Enrollment Fee Submitted:
Payment Method:
Check
or
Credit Card
If using a credit card, complete and return the Credit Card Payment Form
along with this completed application.
Note: SSA will not refund the $5,000 enrollment fee. Your submission of the CBSV application form, along with
the enrollment fee, constitutes your acknowledgement and agreement that the enrollment fee is nonrefundable.
5. Enclose your check made out to the Social Security Administration in the amount of $5,000, or a completed Credit
Card Payment Form, and mail it, along with this completed application, to:
Social Security Administration
ATTN: CBSV
6401 Security Boulevard
P.O. Box 17042
Baltimore, MD 21235
6. Email your completed application to ssa.cbsv@ssa.gov.
