Application For A Social Security Card

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SOCIAL SECURITY ADMINISTRATION
Form Approved
Application for a Social Security Card
OMB No. 0960-0066
First
Full Middle Name
Last
NAME
TO BE SHOWN ON CARD
First
Full Middle Name
Last
FULL NAME AT BIRTH
1
IF OTHER THAN ABOVE
OTHER NAMES USED
Social Security number previously assigned to the person
2
listed in item 1
DATE
Office
PLACE
Use
4
3
OF
OF BIRTH
Only
MM/DD/YYYY
BIRTH
City
State or Foreign Country
FCI
(Do Not Abbreviate)
Legal Alien
Legal Alien Not Allowed
Other (See
CITIZENSHIP
5
Allowed To
To Work (See
Instructions On
U.S. Citizen
(Check One)
Work
Instructions On Page 3)
Page 3)
ETHNICITY
RACE
Other Pacific
Native Hawaiian
American Indian
Islander
Are You Hispanic or Latino?
Select One or More
6
7
Black/African
Alaska Native
White
(Your Response is Voluntary)
(Your Response is Voluntary)
American
Yes
No
Asian
SEX
8
Male
Female
PARENT/ MOTHER'S
A.
Last
First
Full Middle Name
NAME AT HER BIRTH
9
PARENT/ MOTHER'S SOCIAL
B.
SECURITY NUMBER
Unknown
(See instructions for 9 B on Page 3)
First
Full Middle Name
Last
PARENT/ FATHER'S NAME
A.
1 0
B.
PARENT/ FATHER'S SOCIAL SECURITY
Unknown
NUMBER
(See instructions for 10B on Page 3)
Has the person listed in item 1 or anyone acting on his/her behalf ever filed for or received a Social Security number
1 1
card before?
Don't Know (If "don't know," skip to question 14.)
Yes (If "yes" answer questions 12-13)
No
Name shown on the most recent Social
First
Full Middle Name
Last
1 2
Security card issued for the person
listed in item 1
Enter any different date of birth if used on an
1 3
earlier application for a card
MM/DD/YYYY
TODAY'S
DAYTIME
1 4
1 5
DATE
PHONE NUMBER
MM/DD/YYYY
Area Code
Number
Street Address, Apt. No., PO Box, Rural Route No.
1 6
MAILING ADDRESS
City
State/Foreign Country
ZIP Code
(Do Not Abbreviate)
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms,
and it is true and correct to the best of my knowledge.
1 7
YOUR SIGNATURE
YOUR RELATIONSHIP TO THE PERSON IN ITEM 1 IS:
I
1 8
Natural Or
Other
Specify
Self
Legal
Adoptive Parent
Guardian
DO NOT WRITE BELOW THIS LINE (FOR SSA USE ONLY)
NPN
DOC
NTI
CAN
ITV
PBC
EVI
EVA
EVC
PRA
NWR
DNR
UNIT
EVIDENCE SUBMITTED
SIGNATURE AND TITLE OF EMPLOYEE(S) REVIEWING
EVIDENCE AND/OR CONDUCTING INTERVIEW
DATE
DCL
DATE
Page 5
Form SS-5 (08-2011)
ef (08-2011)
Destroy Prior Editions
(0007)
1W9996 3.000

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