Authorization for the Social Security Administration (SSA) To Release Social Security Number (SSN) Verification

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I want this information released because I am conducting the following business transaction:
(We prefilled this one for you)
Reason (s) for using CBSV:
(We also prefilled this one for you)

with the following company ("the Company")

Company Name: Bela Flor Nurseries, Inc.
Company Address: 28615 S E Outer Rd. Harrisonville, MO 64701
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:
HireRight, Inc. 14002 E. 21st Street, Suite 1200, Tulsa, OK 74134
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 90 days from the date signed

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Form SSA-89 (06-2013)

Paperwork Reduction Act Statment

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.
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