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Ss 5

This 3 sentence summary provides the key details about applying for a Social Security card: The document is an application for a Social Security card which requests the applicant's name, date of birth, place of birth, mother's and father's identifying information, citizenship status, gender, race, and mailing address. The applicant must declare under penalty of perjury that the information provided is true and correct, and sign and date the application. Upon approval, the Social Security Administration will issue a Social Security card to the applicant.

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elhorseboxo
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972 views

Ss 5

This 3 sentence summary provides the key details about applying for a Social Security card: The document is an application for a Social Security card which requests the applicant's name, date of birth, place of birth, mother's and father's identifying information, citizenship status, gender, race, and mailing address. The applicant must declare under penalty of perjury that the information provided is true and correct, and sign and date the application. Upon approval, the Social Security Administration will issue a Social Security card to the applicant.

Uploaded by

elhorseboxo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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SOCIAL SECURITY ADMINISTRATION

Application for a Social Security Card


NAME

Form Approved
OMB No. 0960-0066

First

Full Middle Name

Last

First

Full Middle Name

Last

TO BE SHOWN ON CARD

FULL NAME AT BIRTH


IF OTHER THAN ABOVE
OTHER NAMES USED ON YOUR
SOCIAL SECURITY CARD

Social Security number previously assigned to the person


listed in item 1

PLACE
OF BIRTH

Office
Use
Only

(Do Not Abbreviate)

City

State or Foreign Country

CITIZENSHIP
(Check One)

Select One or More


(Your Response is Voluntary)

SEX

Male

A. MOTHER'S NAME AT
HER BIRTH

DATE
OF
BIRTH

MM/DD/YYYY

Legal Alien Not


Allowed To Work (See
Instructions On Page 3)

Other
(See Instructions
On Page 3)

Native Hawaiian

American Indian

Other Pacific Islander

Alaska Native

Black/African American

White

Asian

No

Yes

RACE

Are You Hispanic or Latino?


(Your Response is Voluntary)

FCI
Legal Alien
Allowed To
Work

U.S. Citizen

ETHNICITY

Female

First

Full Middle Name

Last Name At Her Birth

B. MOTHER'S SOCIAL SECURITY


NUMBER (See instructions for 9 B on Page 3)
First

Full Middle Name

Unknown
Last

A. FATHER'S NAME

10 B. FATHER'S SOCIAL SECURITY

NUMBER (See instructions for 10B on Page 3)

11
12

Unknown

Has the person listed in item 1 or anyone acting on his/her behalf ever filed for or received a Social Security number
card before?
Yes (If "yes" answer questions 12-13)

Don't Know (If "don't know,"


skip to question 14.)

No

Name shown on the most recent Social


Security card issued for the person
listed in item 1

First

Full Middle Name

any different date of birth if used on an


13 Enter
earlier application for a card

TODAY'S

14 DATE

MM/DD/YYYY

15 DAYTIME
PHONE NUMBER

MM/DD/YYYY

Last Name

Area Code

Number

Street Address, Apt. No., PO Box, Rural Route No.

16 MAILING ADDRESS

State/Foreign Country

City

(Do Not Abbreviate)

ZIP Code

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.

17 YOUR SIGNATURE

18

YOUR RELATIONSHIP TO THE PERSON IN ITEM 1 IS:


Self

Natural Or
Adoptive Parent

Legal
Guardian

Other (Specify)

DO NOT WRITE BELOW THIS LINE (FOR SSA USE ONLY)


NPN
PBC

DOC
EVI

EVA

EVC

NTI

CAN

PRA

NWR

ITV
DNR

UNIT

SIGNATURE AND TITLE OF EMPLOYEE(S) REVIEWING


EVIDENCE AND/OR CONDUCTING INTERVIEW

EVIDENCE SUBMITTED

DATE
DCL

Form SS-5 (08-2009)

ef (08-2009)

Destroy Prior Editions

Page 5

DATE

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