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  • Ssal 996

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    Jerome Means
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    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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    ssal996

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    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.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    50 views1 page

    Ssal 996

    Uploaded by

    Jerome Means
    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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    © All Rights Reserved
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    of 1

    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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