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Ssal 996

This document is a request form for an extract or photocopy of an individual's social security number record. It requests identifying information such as the individual's social security number, full name, date and place of birth, mother and father's names, and signature to verify identity. It notes that providing false information is a criminal offense subject to a $5,000 fine. The completed form should be mailed to a specified address for processing within 4 to 6 weeks.

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Jerome Means
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151 views

Ssal 996

This document is a request form for an extract or photocopy of an individual's social security number record. It requests identifying information such as the individual's social security number, full name, date and place of birth, mother and father's names, and signature to verify identity. It notes that providing false information is a criminal offense subject to a $5,000 fine. The completed form should be mailed to a specified address for processing within 4 to 6 weeks.

Uploaded by

Jerome Means
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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Form SSA-L996 (01-2020)

Discontinue Prior Editions


Page 1 of 1 Social Security Administration

Social Security Number Record


Request for Extract or Photocopy
INSTRUCTIONS: Print or type all data. Sign in ink. Allow 4 to 6 weeks for a reply.

I hereby request an extract or photocopy of my application(s) for a social security number. To establish my identity and to verify
my social security number, I am furnishing my full identifying information, as follows.

Social Security Number (if known) Full Name Used

Name Shown on Last Social Security Card (if different from full name now used)

Full Name at Birth

Date of Birth (MM/DD/YYYY)

Place of Birth (city, county, and state or foreign country) Gender

Male

Female

Full Maiden Name of Mother (whether living or deceased)

Full Name of Father (whether living or deceased)

PENALTY STATEMENT (read before signing) I am the person to whom this record pertains and I understand that to knowingly
and willfully petition or acquire information from a person's Social Security record under false pretenses is a criminal offense
subject to a $5,0000 fine.
Signature (do not print unless this is your usual signature) Date

Street Address City, State, and ZIP Code

NOTE: A printed signature or a signature by mark (X) must be witnessed below by two adults.
1. Signature 2. Signature

Street Address Street Address

City, State, and ZIP Code City, State, and ZIP Code

Mail to: DEBS Enumeration Unit


PO Box 33000
Baltimore, MD 21290-3000

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