Form Ssa 89 - Social Security Administration Authorization For The Social Security Administration (Ssa) Page 3

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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
Form SSA 89 (Page 2 of 2)
User Agreement Between SSA and Requesting Party for CBSV
Revised 6/13

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