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Get SSA-89 2020

Form SSA-89 02-2018 Discontinue Previous Editions Social Security Administration Page 1 of 2 OMB No.0960-0760 Authorization for the Social Security Administration SSA To Release Social Security Number SSN Verification Printed Name Date of Birth I want this information released because I am conducting the following business transaction Reason s for using CBSV Please select all that apply Mortgage Service Banking Service Background Check License Requirement Credit Check Other with the following company the Company Company Name Company Address 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 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 Signature days from the date signed* 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 Please initial* Privacy Act Statement Collection and Use of Personal Information Sections 205 a and 1106 of the Social Security Act as amended allow us to collect this information* Furnishing us this information is voluntary. However failing to provide all or part of the information may prevent us from releasing information to a designated company or company s agent. We will use the information to verify your name and Social Security number SSN. In addition we may share this information in accordance with the Privacy Act and other Federal laws. For example where authorized we may use and disclose this information in computer matching programs in which our records are compared with other records to establish or verify a person s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs. A list of routine uses is available in our Privacy Act System of Records Notice SORN 60-0058 entitled Master Files of SSN Holders and SSN Applications. Additional information and a full listing of all our SORNs are available on our website at www. socialsecurity. gov/foia/bluebook. 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.

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