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

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

Statement of Late Filing in Connection to SSN Application

(Required for 1

time applicants 12 years old and over)

I have never applied before for a Social Security Number

[

] for myself

[

] for my child;

because – ______________________________________________________________________________

_________________________________________________________________________________________

_____________________________________________________________________________________

I give the Social Security Administration permission to verify my birth record with the Bureau of Vital Statistics

or other issuing agency in order to complete the processing of my request for a Social Security Number.

Name: _____________________________________

Date/ Place of Birth: _________________________

_____________________________________________

Signature Over Printed Name of Applicant or

Person Answering the Form for the Applicant

Date: __________________________

-----------------------------------------

OFFICE USE ONLY

Mandatory Interview Certificate

Required for 1

time applicants 12 years old and over

To:

Social Security Administration

FROM:

__________________________________________

U.S. Embassy / Consulate / U.S. Military Command

I certify that __________________________________, whose date of birth is ____________________

personally appeared before me to apply for a Social Security Number. The person stated that he/she has

nor

never applied for

been assigned a Social Security Number before.

______________________________________

________________

Name and Signature of Certifying Officer

Date

Official Designation:

Office Address:

Contact Numbers:

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