SSA-89

Authorization for the Social Security Administration To Release Social Security Number Verification

Download and Print the SSA-89

Printed Name:  
Date of Birth:
Social Security Number:

I am conducting the following business transaction:
[Identify a specific purpose. Example-seeking a mortgage from the Company- "identity verification" or "identity proof or confirmation" is not acceptable.] with the following company ("the Company"):

Company Name:
Company 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:
Name:
Address:

I am the individual to whom the Social Security number was issued or that person's legal guardian. 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
Contact information of individual signing authorization:
Address - City

And much more...