SSA-119 Government to Government Services Online Website Account

Government to Government Services Online Website Account Modification/Deletion Form

Sponsors should complete this form to request modification or deletion of an eData website user account. Sponsors will forward the completed form via email to UIT.eData.Mailbox@ssa.gov. Sponsors will receive email notification when the request has been processed.

Please tab from field to field.

REQUEST INFORMATION

Date of Request:      

Type of Request:

Rationale:      

MODIFICATION REQUEST

Select the utilities to which the user will need access:

(select all that apply to this user)

Comments:      

USER ACCOUNT INFORMATION

User Name (Main Contact for Shared User Account):      

Organization Name:      

Organization ID:      

Email Address:      

Phone (Include area code):      

SPONSOR INFORMATION
Sponsor Name:      	Phone:       (Include area code)
Office:      

ACCOUNT STATUS - For Completion By eData Administrator
Status:	Completion Date:      
Processed by:      	Phone:       (Include area code)
Comments:      

05/07