Form Ssa-89 - Authorization For The Social Security Administration (Ssa) To Release Social Security Number (Ssn) Verification

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Form SSA-89
Form Approved
OMB #0960-0760
Social Security Administration
Authorization for the Social Security Administration (SSA)
To Release
Social Security Number (SSN) Verification
Printed Name_______________________________________________________________________________
Date of Birth __________________________________SSN _________________________________________
I am conducting the following business transaction
Application for Credit
___________________________________________________________________________________________
[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
Address
New Penn Financial LLC
4000 Chemical Road, Suite 300, Plymouth Meeting, PA
___________________________________________________________________________________________
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 Veri-tax, Inc.,
17842 Irvine Blvd. Suite 238 Tustin, California 92780.
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/State/Zip ______________________________________________
Phone Number ______________________________________________
Form SSA-89

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