SSA-89 Form (2022)

Form SSA-89 (12-2020)
Discontinue Prior Editions (;$03/(

Social Security Administration OMB No.0960-0760
Authorization for the Social Security Administration (SSA)
To Release Social Security Number (SSN) Verification
Printed Name: Date of Birth: Social Security Number:
Type your full legal name: First Middle Last Suffix Type your DOB: mm/dd/yyyy Type your SSN: 123-45-6789
Reason for authorizing consent: (Please select one)
To apply for a mortgage To apply for a loan To meet a licensing requirement
To open a bank account To open a retirement account Other
To apply for a credit card To apply for a job

With the following company ("the Company"):
Company Name: Department of Homeland Security (ICE/OPR/PSO)
Company Address: 4050 Alpha Road, Suite 1200, Farmers Branch, TX 75244
The name and address of the Company's Agent (if applicable):
Agent's Name:
Agent's Address: 245 Bellevue Ave., Hammonton, NJ 08037

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. 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 one-time use. 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:
Hand-written
This consent is valid for days from the date signed. initials here (Please initial.)
Signature: Hand-written signature required Date Signed: Type the date signed: mm/dd/yyyy
Relationship (if not the individual to whom the SSN was issued):
Privacy Act Statement Collection and Use of Personal Information

Sections 205(a) and 1106 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this
information is voluntary. However, failing to provide all or part of the information may prevent us from releasing information to a
designated company or company’s agent. We will use the information to verify your name and Social Security number (SSN). In
addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs. A list of routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0058,
entitled Master Files of SSN Holders and SSN Applications. Additional information and a full listing of all our SORNs are available
on our website at www.socialsecurity.gov/foia/bluebook.
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/cbsv/docs/SampleUserAgreement.pdf.
Form SSA-89 (12-2020)
Discontinue Prior Editions
Social Security Administration OMB No.0960-0760
Authorization for the Social Security Administration (SSA)
To Release Social Security Number (SSN) Verification
Printed Name: Date of Birth: Social Security Number:
Reason for authorizing consent: (Please select one)

To apply for a mortgage To apply for a loan To meet a licensing requirement
To open a bank account To open a retirement account Other
To apply for a credit card To apply for a job

With the following company ("the Company"):
Company Name: Department of Homeland Security (ICE/OPR/PSO)
Company Address: 4050 Alpha Road, Suite 1200, Farmers Branch, TX 75244
The name and address of the Company's Agent (if applicable):
Agent's Name:
Agent's Address: 245 Bellevue Ave., Hammonton, NJ 08037

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. 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 one-time use. 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):
Privacy Act Statement Collection and Use of Personal Information

Sections 205(a) and 1106 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this
information is voluntary. However, failing to provide all or part of the information may prevent us from releasing information to a
designated company or company’s agent. We will use the information to verify your name and Social Security number (SSN). In
addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where
authorized, we may use and disclose this information in computer matching programs, in which our records are compared with
other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs. A list of routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0058,
entitled Master Files of SSN Holders and SSN Applications. Additional information and a full listing of all our SORNs are available
on our website at www.socialsecurity.gov/foia/bluebook.
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/cbsv/docs/SampleUserAgreement.pdf.

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SSA-89 Form (2022)

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Form SSA-89 (12-2020)

Discontinue Prior Editions (;$03/(

To apply for a credit card To apply for a job

Agent's Address: 245 Bellevue Ave., Hammonton, NJ 08037

Privacy Act Statement Collection and Use of Personal Information

NOTICE TO NUMBER HOLDER

Reason for authorizing consent: (Please select one)

To apply for a credit card To apply for a job

Agent's Address: 245 Bellevue Ave., Hammonton, NJ 08037

Signature: Date Signed:

Privacy Act Statement Collection and Use of Personal Information

NOTICE TO NUMBER HOLDER

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