Social Security Number Form printable pdf download

Social Security Number Form

DIRECT REIMBURSEMENT

SOCIAL SECURITY NUMBER FORM

This form is only for parents who are or may be eligible for reimbursement from the New York City

Department of Education (NYC DOE) for direct payments made by parents to outside vendors for

services or tuition for their children with disabilities. Use of this form for any other purpose is not

authorized and may delay payments from the City of New York or the NYC DOE. If you are eligible for

or seek other forms of payment from the City of New York or the NYC DOE, you may be required to

complete a W‐9 form for that purpose.

Parent Name _____________________________

Phone Number ___________________________

Address: __________________________________________________________________________

City: _______________________ State _____________ Zip Code _________________________

Primary Phone Number: _______________ Alternative Contact Number: _____________________

Parent’s Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___

Child Name: _______________________________________

IHO Case Number: _________________________________

Certification: Under penalties of perjury, I certify that the number shown on this form is my correct

social security number.

Signature: ______________________________

Date: __________________________________

Parent

Please return this form to:

New York City Department of Education

Impartial Hearing Order Implementation Unit

65 Court Street, Room 1503

Brooklyn, New York 11201

Substitute W‐9

Rev: 8/14 mdg

Social Security Number Form