Form SSA-120 Application For Access to SSA Systems

Form Approved.
OMB 0960-0791

Social Security Administration

APPLICATION FOR ACCESS TO SSA SYSTEMS
(TYPE OR PRINT CLEARLY- ALL ILLEGIBLE FORMS WILL BE RETURNED)
1. APPLICANT INFORMATION

2. TYPE OF REQUEST (Please enter all previously issued PINS/TSO IDS)
NON SSA EMPLOYEE

SSA EMPLOYEE

2A.

CREATE NEW

2B.

CHANGE ACCESS/LOC/ORG
PIN

PIN
TSO ID

(Please specify) SEE INSTRUCTIONS

3A. ENVIRONMENT FOR ACCESS (Check only one)
PRODUCTION

TSO ID

3B. ESEF only (Check all that apply)
ESEF TSO/BATCH

INTEGRATION

ESEF CICS TEST

LAN ONLY

ESEF CICS VALIDATION

ESEF (Complete block 3B)
4. (PRINT) LAST NAME

FIRST (OFFICIAL)

MI

7. SSA COMPONENT NAME OR EXTERNAL ORGANIZATION NAME

5. SOCIAL SECURITY NUMBER

6. OFFICE/BRANCH CODE

8. POSITION TITLE (See Instructions)

9. JUSTIFICATION/REMARKS

10. I HAVE READ AND UNDERSTAND THE SECURITY REQUIREMENTS AND
PRIVACY ACT STATEMENT ON PAGE 2 OF THIS FORM.
11A. APPLICANT'S SIGNATURE

11B. DATE

See continuation sheet

11C. TELEPHONE

RESERVED FOR REQUESTOR’S MANAGEMENT AUTHORITY
12A. (PRINT) REQUESTOR’S MANAGEMENT OFFICIAL’S NAME

12B. REQUESTOR’S MANAGEMENT OFFICIAL’S SIGNATURE

12C. TITLE

12E. REQUESTOR’S MAILING ADDRESS

12D. TELEPHONE

12F. DATE

RESERVED FOR REVIEWING SECURITY AUTHORITY
13A. (PRINT) REVIEWING SECURITY OFFICIAL’S NAME CDSI/CSO

13B. REVIEWING SECURITY OFFICIAL’S MAILING ADDRESS

13C. REVIEWING SECURITY OFFICIAL’S SIGNATURE

13D. DATE

13E. TELEPHONE

13F. COMPONENT/REGION

RESERVED FOR FINAL APPROVING AUTHORITY
14A. (PRINT) APPROVING OFFICIAL'S NAME

14B. APPROVING OFFICIAL’S SIGNATURE

14C. TITLE

14D. TELEPHONE

14F. DATE RECEIVED

14I. PIN/TSO ID EXPIRES:

16.

14G. PIN/TSO ID

14H. BASE PROFILE

15. IF YOU HAVE ANY QUESTIONS CONTACT:

ACCESS DENIED (REASON)

Form SSA-120 (08-2012)

Page 1

14E. DATE

SECURITY REQUIREMENTS FOR USERS OF
SSA'S COMPUTER SYSTEMS
You should be aware that your PIN/ID serves as your "electronic signature" on all systems transactions for which it is
used. This means that you will be held responsible if someone else uses it in connection with a systems transaction.
To monitor the users of SSA's computer systems for compliance with these requirements, SSA records all systems
transactions and conducts routine reviews for inappropriate or illegal activity.
A violation of any of the following security requirements could result in termination of systems access privileges and
serious disciplinary action, possibly removal. In addition, Public Law 98-473, Chapter 21 ("Counterfeit Access Device and
Computer Fraud and Abuse Act of 1984"), and Public Law 99-474 ("Computer Fraud and Abuse Act of 1986") provide
criminal penalties for any person accessing a Government-owned or operated computer illegally.
The information below will assist you in carrying out your responsibility in this area.
1. The PIN/ID you are assigned is for your use only. Lending it to someone else is a security violation and may result in
disciplinary action against both parties.
2. Never disclose your password. Do not put it in writing. Safeguard it. Your password is the key to one of SSA's most
valuable resources.
3. SSA's computer systems must be used only for work-related purposes which are consistent with the justification on
each user's approved request for systems access privileges. Never use the Agency's computers for activities
inconsistent with SSA's mission.
If you become aware of any violation of these requirements or suspect that your PIN/ID may have been used by
someone else, it is your responsibility to immediately report that information to your security officer.

PRIVACY ACT STATEMENT
Collection and Use of Personal Information
44 U.S.C. § 3543 of the Federal Information Security Management Act of 2002, and Section 205(a) of the Social Security
Act, as amended, authorize us to collect this information. We will use the information you provide to grant and limit access
to SSA computer-based information resources. The information you furnish on this form is voluntary. However, failure to
provide us with the requested information could prevent us from providing you access to SSA computer systems.
We rarely use the information you supply for any purpose other than for determining access to SSA computer systems.
However, we may use it for the administration and integrity of Social Security programs. We may also disclose information
to another person or to another agency in accordance with approved routine uses, which include, but are not limited to the
following:
1. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veterans' Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social
Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare our records
with records kept by other Federal, State, or local government agencies.
A complete list of routine uses for this information is available in our System of Records Notices entitled, Identity
Management System, 60-0361; and, Personal Identification Number File, 60-0214. These notices, additional information
regarding this form, and information regarding our programs and systems, are available on-line at www.socialsecurity.gov
or at your local Social Security office.

Form SSA-120 (08-2012)

Page 2

INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR ACCESS TO SSA- SYSTEMS (SSA-120)
1.

Applicant Information

For non-SSA employees please specify whether you are a contractor, DDS, Host
enrollee, Student, etc. See ISSH Chapter 10 attachment “C” for additional details.

2.

Type of request

• If you do not have a PIN or TSO ID and need one assigned place an “X” in
the appropriate box(es).
• If you have a PIN/TSO ID but need your access privileges, location or
organization changed place an “X” in the appropriate box(es).

3. A.

Environment for access

Place one “X” in the box to indicate what environment you require access to. If
you are applying for ESEF access complete box 3B. If you are not applying for
ESEF skip 3B.

3. B.
4.
5.
6.

SEF environment
Name
Social Security Number
Office/Branch Code

Place an “X” in all applicable boxes for ESEF environment.
Print official name as in personnel records (no nicknames).
Provide the SSN of the person applying for PIN/TSO ID.
Provide the 3-digit office code if you are requesting a PIN. Provide the 3 digit
branch code if you are requested the creation of a TSO ID.

7.

SSA component name or
external organization name

SSA Field employees should enter the name of their field office. SSA non-field
office employees should enter their component name. All others enter the name
of your employing company or agency.

8.

Position Title

9.

Justification/Remarks

• SSA employees – Enter your position title from your most recent SF-50,
Notification of Personnel Action. Claims representatives must also enter their
specialty.
• Non SSA employees – Enter the title commonly used by your company or
organization for your position.
Use this space to justify access privileges needed. If your access is needed for a
specific project or domain provide the information.

10.

Security Requirements and
Privacy Act Statement
11. A. Applicant’s Signature
11. B. Date
11. C. Telephone Number
12. A. Requesting Management
Official’s Name
12. B. Requesting Management
Official’s Signature
12. C. Title
12. D. Telephone Number
12. E. Requesting Management
Official’s Mailing Address
12. F. Date
13. A. Print Reviewing Security
Official’s Name CSO/CDSI
13. B. Reviewing Security Official’s
Mailing Address
13. C. Reviewing Security Official’s
Signature
13. D. Date
13. E. Telephone Number
13. F. Component/Region
14. A. Print Approving Official’s
Name
Form SSA-120 (08-2012)

After reading the Security Requirements and Privacy Act Statement in Block 10,
signature of person named in Block 4 should be provided.
Enter date when signature provided in Block 11. A.
Provide work telephone number including area code for the person in Block 11. A.
A Division Director or higher-level official within the requesting component must
approve and sign the form for personnel in central office components.
Provide signature of person named in Block 12. A.
Provide the title of the person named in Block 12. A.
Provide work telephone number including area code for the person in Block 12. B.
Provide mailing address of person named in Block 12. A.
Enter date when signature provided in Block 12. B.
Provide printed name of the Reviewing Security Official. If you are the security
administrator granting or denying the access skip 13. A-F. Complete your
information in section 14 – 16.
Provide mailing address for person named in Block 13. A.
Signature of person named in Block 13. A. should be entered in this block.
Enter date when signature provided in Block 13. C.
Provide work telephone number including area code for the person in Block 13. A.
Provide component/region for person named in Block 13. A.
Provide printed name of the security administrator granting or denying the access
of applicant.
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INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR ACCESS TO SSA- SYSTEMS (SSA-120)
14. B.
14. C.
14. D.
14. E.
14. F.
14. G.
14. H.
14. I.
15.

Approving Official’s Signature
Title
Telephone Number
Date
Date Received
PIN/TSO ID
Base Profile
PIN/TSO ID
Questions

16.

Access Denied

Signature of the person named in Block 14. A. should be entered in this block.
Provide the title of the person named in Block 14. A.
Provide work telephone number including area code for the person in Block 14. A.
Enter date when signature provided in Block 14. B.
Enter date form was received by the person named in Block 14. A.
Enter the PIN/TSO ID created for the person named in Block 4.
Enter the profile given to the person named in Block 4.
Enter expires date for PIN/TSO ID expiration if applicable.
Enter the name and telephone number including the area code of the person to
call if there are any questions.
Enter the reason for denying the access for the person named in Block 4.

Disposition of the Completed Form

1. Regional, Field and DDS personnel – Send the form through the Local Security Officer to
the appropriate Security Specialist or Regional Security Officer.
2. Office of Disability Adjudication and Review Regional and Field personnel - Send the form
through the Security Officer in the ODAR Regional Office to the Component Security
Officer, 5107 Leesburg Pike, Falls Church, Virginia 22041-3255.
3. For access to the ESEF– Component Security Officer (CSO) should send the
signed/complete form to: OESAE Component Security Officer, 4-N-28 Operations
Building.
4. Other Central Office personnel – Send the form through the appropriate Component
Security Officer for processing.

Form SSA-120 (08-2012)

Page 4

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 (OMB) control number. The OMB control number for this
collection is 0960-0791. We estimate that it will take about 2 minutes to read the
instructions, gather the facts, and answer the questions. Send only comments relating to
our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.