Form Ssa 89 - Social Security Administration Authorization For The Social Security Administration (Ssa) Page 2

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Form SSA 89
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 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 _____
License Requirement_____
Credit Check _____
Other _____
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:
_____________Intellicorp Records, Inc. 3000 Auburn Drive Suite 410, Beachwood OH 44122___________________
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.
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)
User Agreement Between SSA and Requesting Party for CBSV
Revised 6/13

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