Mandatory In-Person Interview Worksheet (Ssn Applicant Age 12 Or Older) (Page 3 of 4) in pdf

Mandatory In-Person Interview Worksheet

SSN Applicant Age 12 or Older – Original SSN

Determine if the applicant has previously been assigned, or has used, an SSN by asking the questions about

circumstances under which he or she may have needed an SSN. The questions listed in this worksheet are

not all inclusive; additional questions may be necessary to ensure an SSN was not previously assigned and to

prevent the assignment of an SSN to an individual assuming a false identity. Document all interview and

development results.

Applicant Name:

___________________________________________

Applicant Address: ___________________________________________

___________________________________________

1. Has the applicant ever held a full-time, part-time or temporary job in the U.S.?

□ No

□ Yes

If yes, explain:

_____________________________________________________________________________________________

2. Has the applicant ever had a U.S. State-issued driver's license, U.S. State ID card?

□ No

□ Yes

If yes, explain:

_____________________________________________________________________________________________

3. Has the applicant ever taken any U.S. Scholastic Achievement Test or other college-related entrance tests?

□ No

□ Yes

If yes, explain:

_____________________________________________________________________________________________

4. Has the applicant ever attended or applied for admittance to a U.S. college, university or

technical/vocational school?

□ No

□ Yes

If yes, explain:

_____________________________________________________________________________________________

5. Has the applicant ever had a U.S. savings account in a bank, credit union, or other financial institution or

ever owned U.S. stocks or U.S. bonds? Did the parents or other relatives ever open an account or buy U.S.

savings bonds for the applicant?

□ No

□ Yes

If yes, explain:

_____________________________________________________________________________________________

6. Has the applicant or his/her spouse ever filed a U.S. Federal or State income tax return or been claimed as

a dependent on a Federal tax return?

□ No

□ Yes

If yes, explain:

_____________________________________________________________________________________________

7. Has the applicant ever served in the U.S. military service or registered to vote in the U.S.?

□ No

□ Yes

If yes, explain:

_____________________________________________________________________________________________

8. Has the applicant or the applicant's family ever applied for any type of U.S. governmental assistance such

as TANF, Food Stamps, WIC, Medicaid, medical assistance, public job training or summer youth

employment?

□ No

□ Yes

If yes, explain:

_____________________________________________________________________________________________

9. Has the applicant been living outside the U.S. for a prolonged period?

□ No

□ Yes

If yes, explain:

_____________________________________________________________________________________________

Indicate if there were any problems with the applicant's responses and/or if there were any indications that

the responses or evidence was fraudulent.

_________________________________________________________________________________________

_________________________________________________________

_______________________

Signature/Title of Approved Person Who Conducted Interview

Date

Mandatory In-Person Interview Worksheet (Ssn Applicant Age 12 Or Older) Page 3

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