Get Form Ssa 89 2013

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 Form SSA-89 06-2013 Please initial. 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. Form Approved OMB No. 0960-0760 Social Security Administration 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 Credit Check License Requirement 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. 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. 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. 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. 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.