Form Ss-5 - Application For A Social Security Card - Social Security Administration Page 5
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5SOCIAL SECURITY ADMINISTRATION
Form Approved
Application for a Social Security Card
OMB No. 0960-0066
First
Full Middle Name
Last
NAME
TO BE SHOWN ON CARD
FULL NAME AT BIRTH
Full Middle Name
Last
First
1
IF OTHER THAN ABOVE
OTHER NAMES USED
Street Address, Apt. No., PO Box, Rural Route No.
MAILING
2
State
ZIP Code
ADDRESS
City
-
Do Not Abbreviate
Legal Alien
Legal Alien Not
Other
3
CITIZENSHIP
U.S. Citizen
Allowed To
Allowed To Work (See
(See Instructions
Work
Instructions On Page 2)
On Page 2)
(Check One)
4
SEX
Male
Female
North
Asian,
Black
American
White
RACE/ETHNIC
Asian-American
5
Hispanic
(Not
Indian or
(Not
or
DESCRIPTION
Hispanic)
Alaskan
Hispanic)
Pacific Islander
Native
(Check One Only - Voluntary)
Office
DATE
PLACE
Use
6
7
OF
OF BIRTH
Only
BIRTH
Month, Day, Year
(Do Not Abbreviate)
City
State or Foreign Country
FCI
First
Full Middle Name
Last Name At Her Birth
A. MOTHER'S NAME AT
HER BIRTH
8
-
-
B. MOTHER'S SOCIAL SECURITY
NUMBER
(See instructions for 8B on Page 2)
First
Full Middle Name
Last
A. FATHER'S NAME
9
-
-
B. FATHER'S SOCIAL SECURITY
NUMBER
(See instructions for 9B on Page 2)
Has the applicant or anyone acting on his/her behalf ever filed for or received a Social Security
10
number card before?
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
11
assigned to the person listed in item 1.
Enter the name shown on the most
First
Middle Name
Last
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
14
15
DATE
PHONE NUMBER
Month, Day, Year
Area Code
Number
I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms,
and it is true and correct to the best of my knowledge.
16
YOUR SIGNATURE
YOUR RELATIONSHIP TO THE PERSON IN ITEM 1 IS:
17
Self
Natural Or
Legal
Other (Specify)
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
DCL
DATE
Form SS-5 (05-2006)
ef (05-2006)
Destroy Prior Editions
Page 5
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