Authorization for the Social Security Administration (SSA) To Release Social Security Number (SSN) Verification
with the following company ("the Company")
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:
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
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 http://www.ssa.gov/cbsv/docs/SampleUserAgreement.pdf