Social Security Administration Application For A Social Security Card Page 5
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6Form Approved
OMB No. 0960-0066
SOCIAL SECURITY ADMINISTRATION Application for a Social Security Card
First
Full Middle Name
Last
NAME
TO BE SHOWN ON CARD
FULL NAME AT BIRTH
First
Full Middle Name
Last
1
IF OTHER THAN ABOVE
OTHER NAMES USED
Street Address, Apt. No., PO Box, Rural Route No.
MAILING
2
ADDRESS
City
State
Zip Code
Do Not Abbreviate
Legal Alien
Legal Alien
Other
CITIZENSHIP
3
U.S. Citizen
Allowed To
Not Allowed
(See Instructions
(Check One)
Work
To Work
On Page 1)
4
SEX
Male
Female
North
Asian
RACE/ETHNIC
Black
White
American
Asian-American
5
(Not
Hispanic
(Not
DESCRIPTION
Indian or
or
Hispanic)
Hispanic)
Alaskan
Pacific Islander
(Check One Only—Voluntary)
Native
Office
PLACE OF
DATE
Use
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7
BIRTH
OF
Only
BIRTH
FCI
Month, Day, Year
(Do Not Abbreviate)
City
State or Foreign Country
A.
MOTHER’S MAIDEN
First
Full Middle Name
Last Name At Her Birth
NAME
8
B. MOTHER’S SOCIAL SECURITY
NUMBER
(Complete only if applying for a number for a child under age 18.)
First
Full Middle Name
Last
A
. FATHER’S NAME
9
B. FATHER’S SOCIAL SECURITY
NUMBER
(Complete only if applying for a number for a child under age 18.)
Has the applicant or anyone acting on his/her behalf ever filed for or received a Social Security
number card before?
10
Don’t Know (If “don’t know”,
Yes (If “yes”, answer questions 11-13.)
No (If “no”, go on to question 14.)
go on to question 14.)
Enter the Social Security number previously
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assigned to the person listed in item 1.
First
Middle
Last
Enter the name shown on the most
12
recent Social Security card issued for
the person listed in item 1.
Enter any different date of birth if used on an
13
earlier application for a card.
Month, Day, Year
TODAY’S
DAYTIME
(
)
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15
DATE
PHONE NUMBER
Month, Day, Year
Area Code
Number
DELIBERATELY FURNISHING (OR CAUSING TO BE FURNISHED) FALSE INFORMATION ON THIS APPLICATION IS A CRIME PUNISHABLE BY FINE OR IMPRISONMENT, OR BOTH.
YOUR SIGNATURE
YOUR RELATIONSHIP TO THE PERSON IN ITEM 1 IS:
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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) REVIEW-
ING EVIDENCE AND/OR CONDUCTING INTERVIEW
DATE
DATE
DCL
Form SS-5 Internet (2-98) Destroy Prior Editions
Page 5
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