Form SSA-89. Authorization for the Social Security Administration (SSA) to Release Social Security Number (SSN) Verification

Form SSA-89 serves as an authorization from an individual to the Social Security Administration (SSA) for releasing Social Security Number (SSN) verification to a designated company or its agent. The form ensures that personal information, specifically the individual's name and SSN, is disclosed for a specific purpose identified by the individual. It includes consent for this disclosure, affirmations, a privacy act statement, and a tear-off notice to the number holder.

Key Sections and Fields:

Authorization Details:

• Name and Address of the Company's Agent (if applicable):
• Agent's Name: Name of the company's designated agent.
• Agent's Address: Address of the company's designated agent.

Authorization Statement:

• The individual's authorization for SSA to verify their name and SSN to the company or its agent.
• Identification of the individual as the SSN holder, parent/legal guardian of a minor, or legal guardian of a legally incompetent adult.
• Affirmation under penalty of perjury that the information provided is accurate.
• Acknowledgment of potential penalties for making false representations to obtain information from SSA records.

Consent Validity:

• Clarification that the consent is for a one-time use only.
• Consent validity period of 90 days from the date signed, unless specified otherwise.

Signature and Date:

• Individual's signature.
• Date the form was signed.

Relationship (if not the individual to whom the SSN was issued):

• Relationship of the person signing the form to the SSN holder.

Privacy Act Statement:

• Explanation of the legal basis for collecting the information under the Social Security Act.
• Statement about voluntary submission of information and potential consequences of not providing the information.
• Use of the collected information for verifying name and SSN, sharing with contractors and federal agencies for program administration, and for authorized purposes under the Privacy Act.
• Mention of routine uses, computer matching programs, and privacy protections.
• Reference to the Privacy Act System of Records Notice (SORN) for further details.

Paperwork Reduction Act Statement:

• Statement regarding compliance with the Paperwork Reduction Act.
• Estimated time required to complete the form.
• Contact information for sending comments about the burden estimate.

Tear-Off Notice:

• Notice to the number holder about the company's agreement with SSA and its restrictions on the use and disclosure of SSN verification.

Purpose: Form SSA-89 serves as a legal document to authorize the release of SSN verification by SSA to designated companies or agents. It aims to protect the privacy of individuals by ensuring that SSN information is shared only for legitimate purposes and under specified conditions. The form includes consent, affirmations, privacy safeguards, and necessary disclosures to promote transparency and compliance with applicable laws.