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Get SSA-89 2008

Form SSA-89 Form Approved OMB 0960-0760 Social Security Administration Authorization for the Social Security Administration SSA To Release Printed Name Date of BirthSSN I am conducting the following business transaction seeking a mortgage with the following company the Company Company Name Address th ISU Credit Union 707 S. 9 Ave. Pocatello Idaho 83201 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 that person s legal guardian* 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 Signature Date Signed Contact information of individual signing authorization Address City/State/Zip Phone Number Form SSA-89 8/15/2008 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 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. Pocatello Idaho 83201 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 that person s legal guardian* 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. 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. .

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