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Ss 5
Ss 5
may also grant exceptions to these limits if you provide evidence from an official source to establish that a Social Security card is required. IF YOU HAVE ANY QUESTIONS If you have any questions about this form or about the evidence documents you must provide, please visit our website at www.socialsecurity.gov for additional information as well as locations of our offices and Social Security Card Centers. You may also call Social Security at 1800-772-1213. You can also find your nearest office or Card Center in your local phone book.
Form SS-5 (08-2011) ef (08-2011) Destroy Prior Editions Page 1
EVIDENCE DOCUMENTS The following lists are examples of the types of documents you must provide with your application and are not all inclusive. Call us at 1-800-772-1213 if you cannot provide these documents. IMPORTANT : If you are completing this application on behalf of someone else, you must provide evidence that shows your authority to sign the application as well as documents to prove your identity and the identity of the person for whom you are filing the application. We can only accept original documents or documents certified by the custodian of the original record. Notarized copies or photocopies which have not been certified by the custodian of the record are not acceptable. Evidence of Age In general, you must provide your birth certificate. In some situations, we may accept another document that shows your age. Some of the other documents we may accept are: U.S. hospital record of your birth (created at the time of birth) Religious record established before age five showing your age or date of birth Passport Final Adoption Decree (the adoption decree must show that the birth information was taken from the original birth certificate) Evidence of Identity You must provide current, unexpired evidence of identity in your legal name. Your legal name will be shown on the Social Security card. Generally, we prefer to see documents issued in the U.S. Documents you submit to establish identity must show your legal name AND provide biographical information (your date of birth, age, or parents' names) and/or physical information (photograph, or physical description - height, eye and hair color, etc.). If you send a photo identity document but do not appear in person, the document must show your biographical information (e.g., your date of birth, age, or parents' names). Generally, documents without an expiration date should have been issued within the past two years for adults and within the past four years for children. As proof of your identity, you must provide a: U.S. driver's license; or U.S. State-issued non-driver identity card; or U.S. passport If you do not have one of the documents above or cannot get a replacement within 10 work days, we may accept other documents that show your legal name and biographical information, such as a U.S. military identity card, Certificate of Naturalization, employee identity card, certified copy of medical record (clinic, doctor or hospital), health insurance card, Medicaid card, or school identity card/record. For young children, we may accept medical records (clinic, doctor, or hospital) maintained by the medical provider. We may also accept a final adoption decree, or a school identity card, or other school record maintained by the school. If you are not a U.S. citizen, we must see your current U.S. immigration document(s) and your foreign passport with biographical information or photograph. WE CANNOT ACCEPT A BIRTH CERTIFICATE, HOSPITAL SOUVENIR BIRTH CERTIFICATE, SOCIAL SECURITY CARD STUB OR A SOCIAL SECURITY RECORD as
evidence of identity. Evidence of U.S. Citizenship In general, you must provide your U.S. birth certificate or U.S. Passport. Other documents you may provide are a Consular Report of Birth, Certificate of Citizenship, or Certificate of Naturalization. Evidence of Immigration Status You must provide a current unexpired document issued to you by the Department of Homeland Security (DHS) showing your immigration status, such as Form I-551, I-94, or I-766. If you are an international student or exchange visitor, you may need to provide additional documents, such as Form I-20, DS-2019, or a letter authorizing employment from your school and employer (F-1) or sponsor (J-1). We CANNOT accept a receipt showing you applied for the document. If you are not authorized to work in the U.S., we can issue you a Social Security card only if you need the number for a valid non-work reason. Your card will be marked to show you cannot work and if you do work, we will notify DHS. See page 3, item 5 for more information.
Form SS-5 (08-2011) ef (08-2011) Page 2
In most cases, you can take or mail this signed application with your documents to any Social Security office. Any documents you mail to us will be returned to you. Go to https://secure.ssa.gov/apps6z/FOLO/fo001.jsp to find the Social Security office or Social Security Card Center that serves your area.
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PROTECT YOUR SOCIAL SECURITY NUMBER AND CARD Protect your SSN card and number from loss and identity theft. DO NOT carry your SSN card with you. Keep it in a secure location and only take it with you when you must show the card; e.g., to obtain a new job, open a new bank account, or to obtain benefits from certain U.S. agencies. Use caution in giving out your Social Security number to others, particularly during phone, mail, email and Internet requests you did not initiate.
Applications). The Notice, additional information regarding this form, and information regarding our systems and programs, are available on-line at www.socialsecurity.gov or at any local Social Security office.
This information collection meets the requirements of 44 U.S.C. 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995 . You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 8.5 to 9.5 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
Form SS-5 (08-2011) ef (08-2011) Page 4
1
Form Approved OMB No. 0960-0066 NAME TO BE SHOWN ON CARD First Full Middle Name Last FULL NAME AT BIRTH IF OTHER THAN ABOVE Robert Thomas Romero First Full Middle Name Last OTHER NAMES USED
Rob,R. 2 Social Security number previously assigned to the person listed in item 1 5 3 2 0 6 1 1 8 8
3
Bremerton Washington
- PLACE OF BIRTH (Do Not Abbreviate) City - () Destroy Prior Editions Office Use Only
DATE OF
State or Foreign Country FCI
BIRTH
MM/DD/YYYY
5 CITIZENSHIP
( Check One )
4
08/12/1985
Legal Alien Allowed To Work Shirley Ann Best Mark Franklin Romero
6
Legal Alien Not Allowed U.S. Citizen To Work(See Instructions On Page 3) Other Pacific Islander White
8
SEX Male Female
9
ETHNICITY Are You Hispanic or Latino? (Your Response is Voluntary) Yes No RACE Select One or More (Your Response is Voluntary) Native Hawaiian Alaska Native Asian American Indian 7 Black/African American
- Unknown
Unknown
11
Has card the person listed in item 1 or anyone acting on his/her behalf ever filed for or received a Social Security number 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 12
Security listed in item card 1 issued for the person 13 Enter earlier any application different for date a card of birth if used on an
MM/DD/YYYY
14
TODAY'S DATE
MM/DD/YYYY
15
Street Address, Apt. No., PO Box, Rural Route No. City State/Foreign Country 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, 17
18
YOUR Self
RELATIONSHIP Natural Or
Adoptive Parent TO THE PERSON IN ITEM 1 IS: Legal Guardian Other Specify DO NOT WRITE BELOW THIS LINE (FOR SSA USE ONLY ) NPN DOC NTI CAN ITV PBC EVI EVA EVC PRA NWR DNR UNIT EVIDENCE SUBMITTED
SIGNATURE AND TITLE OF EMPLOYEE(S) REVIEWING EVIDENCE AND/OR CONDUCTING INTERVIEW DATE DCL DATE Form SS-5 (08-2011) ef (08-2011) Page 5
USU