SOCIAL SECURITY ADMINISTRATION
STATEMENT OF CLAIMANT OR OTHER PERSON
Understanding that this statement is for the use of the Social Security Administration, I hereby certify that -
I have been assigned a Social Security Number, which I am unable to locate.
I request the Federal Benefits Unit to provide me with my Social Security Number.
(Please complete the following identifying information in regard to the Social Security Number).
Full Name:
__________________________________________________
Full name on most recent SSN Card:
(First Name)
(Middle Name)
(Surname)
Date of Birth:
__________________________________________________
Place of Birth:
__________________________________________________
Fathers Full Name:
__________________________________________________
Mothers Full Name/Maiden Name:
__________________________________________________
Full Address
____________________________________________
(Street)
_________________________________________
(Town/City)
______________________(
______________
(County)
Post Code)
□
I have attached original proof of my identity with this request.
YES
I fully understand that there are criminal penalties for making a knowing and willful request for access to
records concerning another individual under false pretenses.
Signature
Date (Month, day, year)
(First name, middle initial, last name)
(Write in ink)
Telephone Number (+ area code)
SIGN HERE
To be returned to
fbu.oslo@ssa.gov
Federal Benefits Unit, American Embassy, Henrik
Ibsens gt 48, 0244 Oslo
Form SSA-795