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Ssal 996
Ssal 996
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.
Name Shown on Last Social Security Card (if different from full name now used)
Male
Female
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
NOTE: A printed signature or a signature by mark (X) must be witnessed below by two adults.
1. Signature 2. Signature
City, State, and ZIP Code City, State, and ZIP Code