Form Ssa-89 - Background Information Sheet - Uconn Health Page 3
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3Privacy 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 (06-2013)
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Parent category: Business