Attestation Statement For Ssa Form 89 printable pdf download

ATTESTATION STATEMENT FOR USING THE “SSA FORM 89 VERIFICATION SERVICE”

Name and address of company requesting services:

Company Name: _________________________________________________________

Address: ________________________________________________________________

EIN: ___________________________________________________________________

I understand that the “SSA Form 89 Verification Service” for which I am applying to access, utilizes the Social Security

Administration’s Consent Based Social Verification Service. In order to be granted access to the CBSV service, I understand our

company must comply with the SSA rules associated with the CBSV service including:

1) We understand that Social Security Administration will verify Social Security Numbers solely to ensure that the records of my

Clients are correct for the purpose(s) indicated on the Consent Forms, Form SSA-89 (Authorization for SSA to Release SSN

Verification), obtained from the Clients.

2) We understand the information received from records maintained by the Social Security Administration is protected by Federal

statutes and regulations, including 5 U.S.C. § 552a(i)(3) of the Privacy Act. Under this section, any person who knowingly and

willfully requests or obtains any record concerning an individual from an Agency under false pretenses shall be guilty of a

misdemeanor and fined not more than $5,000.

3) We will only request CBSV SSN verification for an individual from whom our company has obtained a valid consent form (Form

SSA-89).

4) We will notify our service provider if an employee/contractor with access to our CBSV order credentials leaves our company or if

we choose to revoke any or all of our order access credentials for CBSV.

5) We will protect the confidentiality of consent forms (and the information contained on them) and protect the associated record of

SSN verification.

6) We understand that our CBSV service provider reserves the right to unilaterally suspend access to CBSV services if our service

provider or SSA concludes that our company has failed to properly obtain consent or otherwise failed to follow the terms of use

associated with this service.

7) We understand that we may be notified of updated or new terms of use for the CBSV service from time to time and that

compliance with any updated or new conditions will become a condition for continued access to the CBSV service.

8) We understand that each Social Security Number (SSN) submitted will be returned to us with a Verification Code that the

submission either agrees or does not agree with SSA’s records. If SSA’s response is that the submission does not match our

records, we understand that SSA requires the following actions are taken:

a) Review the data submitted to SSA against the data contained in your records. If it does not match, resubmit the corrected data

to SSA for verification. The cost for the resubmission will be borne by you.

b) If the data in your records matches the data submitted to SSA, then re-contact the SSN holder and ask to see his/her Social

Security Card and/or verify the information provided to you to assure that the SSN and name were correctly shown on your

request. If the number holder corrects the original data, then you should submit the corrected data to SSA for verification.

The cost for resubmission will be borne by you.

c) If you cannot resolve the “no match” data discrepancy, then you will refer the SSN holder to the Social Security Field Office

that services where he/she resides to determine the nature of the problem. The servicing SSA Field Office can be located by

visiting Select the “Find a Social Security Office” link and follow the instructions.

d) NOTE: If the Social Security Administration's records are wrong, only the Number Holder can request that the record be

corrected.

9) We understand that in completing the Form SSA-89, the Number Holder needs to state the purpose for the request, and those

general statements such as “Identity Verification” or “Proof of Identity” are not acceptable. Some common purposes may

include:

a) Seeking a mortgage from the company

b) Seeking to rent from the company

c) Background Check or Pre-Employment Screening

d) To be licensed

e) Credit check

f) Seeking employment from the company

g) Seeking to volunteer for the company

10) We acknowledges that Section 1140 of the Social Security Act authorizes SSA to impose civil monetary penalties on any person

who uses the words "Social Security" or other program-related words, acronyms, emblems and symbols in connection with an

advertisement, solicitation or other communication, "in a manner which such person knows or should know would convey, or in a

manner which reasonably could be interpreted or construed as conveying, the false impression that such item is approved,

endorsed, or authorized by the Social Security Administration . . . ." 42 U.S.C. § 1320b-10(a); and

a) We acknowledges that it is specifically prohibited from using the words "Social Security" or other program-related words,

acronyms, emblems and symbols in connection with an advertisement for “identity verification”; and

b) We further acknowledges that it is specifically prohibited from advertising that SSN verification provides or serves as

identity verification; and

Attestation Statement For Ssa Form 89

Related Articles

Related forms

Related Categories