CBSV Enrollment Application SA 200 Form SSA200
User Manual: SA-200
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Social Security Administration CBSV Enrollment Application Form Approved OMB No. 0960-0760 PLEASE TYPE IN THE NECESSARY INFORMATION DATE: 1. Company Identifying Information: Company Name: EIN: DBA (Doing Business As) Name: Telephone: Mailing Address: City: State: Zip: Company Email: 2. Company Official: Responsible Company Official: Telephone(s): Contact Person(s): Email Addresses: 3. Reason (s) for Using CBSV: (select all that apply (x)) Mortgage Service Banking Service Licensing Requirement Other (Specify): Credit Check Background Check 4. CBSV Usage Information: Estimated Annual Volume of Requests: Date Enrollment Fee Submitted: Payment Method: Check or Credit Card If using a credit card, complete and return the Credit Card Payment Form along with this completed application. Note: SSA will not refund the $5,000 enrollment fee. Your submission of the CBSV application form, along with the enrollment fee, constitutes your acknowledgement and agreement that the enrollment fee is nonrefundable. 5. Enclose your check made out to the Social Security Administration in the amount of $5,000, or a completed Credit Card Payment Form, and mail it, along with this completed application, to: Social Security Administration ATTN: CBSV 6401 Security Boulevard P.O. Box 17042 Baltimore, MD 21235 6. Email your completed application to ssa.cbsv@ssa.gov. SSA-200 (12-2010) Destroy Prior Editions
Source Exif Data:
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