Form SSA-89 Authorization for SSA to Release SSN Verification

Form Approved
OMB #0960-0760

Social Security Administration
Authorization for the Social Security Administration (SSA)
To Release
Social Security Number (SSN) Verification
Printed Name ____________________Date of Birth______________SSN ___________
I am conducting the following business transaction
____________________________________________________________________________
[Identify a specific purpose. Example—seeking a mortgage from the Company– “identity
verification” or “identity proof or confirmation” is not acceptable.].
with the following company (“the Company”):
Company Name

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.
Reason (s) for using CBSV: (Please select all that apply)
Mortgage Service ______ Banking Service _____
Background Check _____ License Requirement _____
Credit Check _____
Other _____
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:
This consent is valid for _______ days from the date signed. _______ (Please initial.)
Signature __________________________________ 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 (Page 1 of 2)

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. § 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. 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.
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.ssa.gov/bso/cbsvPDF/agreement.pdf

Form SSA 89 (Page 2 of 2)