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Social Security Card Application Form

The document is an application for a Social Security card that collects information such as name, date and place of birth, citizenship status, parents' names and Social Security numbers, and previous Social Security numbers if applicable. Applicants must declare that the information provided is true and correct and sign the application, which is reviewed by Social Security Administration employees.

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Gino Laurella
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103 views1 page

Social Security Card Application Form

The document is an application for a Social Security card that collects information such as name, date and place of birth, citizenship status, parents' names and Social Security numbers, and previous Social Security numbers if applicable. Applicants must declare that the information provided is true and correct and sign the application, which is reviewed by Social Security Administration employees.

Uploaded by

Gino Laurella
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

SOCIAL SECURITY ADMINISTRATION Form Approved

Application for a Social Security Card OMB No. 0960-0066

NAME First Full Middle Name Last


TO BE SHOWN ON CARD
First Full Middle Name Last
FULL NAME AT BIRTH
1 IF OTHER THAN ABOVE

OTHER NAMES USED

Social Security number previously assigned to the person


2 listed in item 1

PLACE
Office DATE
3 OF BIRTH
Use
Only 4 OF
(Do Not Abbreviate) City State or Foreign Country FCI BIRTH MM/DD/YYYY
Legal Alien Legal Alien Not Allowed Other (See
5 CITIZENSHIP
( Check One )
U.S. Citizen Allowed To
Work
To Work(See
Instructions On Page 3)
Instructions On
Page 3)

ETHNICITY RACE Native Hawaiian American Indian Other Pacific


Islander
Are You Hispanic or Latino? Select One or More
6 (Your Response is Voluntary) 7 (Your Response is Voluntary)
Alaska Native Black/African
American
White
Asian

8 SEX Male Female

A. PARENT/ MOTHER'S First Full Middle Name Last

NAME AT HER BIRTH


9 B. PARENT/ MOTHER'S SOCIAL
SECURITY NUMBER (See instructions for 9 B on Page 3)
First Full Middle Name Last
A. PARENT/ FATHER'S
NAME
10 B. PARENT/ FATHER'S SOCIAL SECURITY
NUMBER (See instructions for 10B on Page 3)
Has the person listed in item 1 or anyone acting on his/her behalf ever filed for or received a Social Security number
11 card before?
Yes (If "yes" answer questions 12-13) No Don't Know (If "don't know," skip to question 14.)
Name shown on the most recent Social First Full Middle Name Last
Security card issued for the person
12 listed in item 1

13 Enter any different date of birth if used on an


earlier application for a card MM/DD/YYYY

TODAY'S DAYTIME PHONE


14 DATE MM/DD/YYYY
15 NUMBER Area Code Number
Street Address, Apt. No., PO Box, Rural Route No.

16 MAILING ADDRESS City State/Foreign Country ZIP Code


(Do Not Abbreviate)
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 to my knowledge.

17 YOUR SIGNATURE 18
YOUR RELATIONSHIP TO THE PERSON IN ITEM 1 IS:
Self
Natural Or
Legal Guardian Other Specify
Adoptive Parent

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


NPN DOC NTI CAN ITV
PBC EVI EVA EVC PRA NWR DNR UNIT
SIGNATURE AND TITLE OF EMPLOYEE(S) REVIEWING
EVIDENCE SUBMITTED
EVIDENCE AND/OR CONDUCTING INTERVIEW

DATE

DCL DATE
Form SS-5 (08-2011) ef (08-2011) Destroy Prior Editions Page 5

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