Form SS-5-FS
Use (11-2024) Uf Until Stock Is Exhausted
SOCIAL SECURITY ADMINISTRATION OMB No.0960-0066
Application for a Social Security Card
NAME: First Full Middle Name Last
TO BE SHOW ON CARD
1
FULL NAME AT BIRT IF First Full Middle Name Last
OTHER THAN ABOVE
OTHER NAME USED
Social Segurity number previously assigned to the person
listed listed in item 1
2
PLACE Office 4
OF Use DATE OF
3 BIRTH Only BIRTH _______________________
(Do not abbreviate) City MM/DD/YYYY
State or Foreign Country FCI
CITIZENSHIP (Checa ⃞ U.S. ⃞ Legal Alien ⃞ Legal Alien Not Allowed To Word ⃞ Other (Se
One)
Citizen Allowed To Work (See Instructions on Page 3) On Page 3)
ETHNICITY Are RACE ⃞ Native Hawaiian ⃞ American Indian ⃞ Other Pacific Isla
You Hispanic or Latino? (Your Select One or
6 Response is Voluntary) 7
More (Your ⃞ Alaska Native ⃞ Black / African American ⃞ White
⃞ Yes ⃞ No Response is ⃞ Native Asían
Voluntary)
8 SEX ⃞ Male ⃞ Famale
A, PARENT/ MOTHER’S First Full Middle Name Last
NAME AT HER BIRTH
9
B, PARENT / MOTHER’S SOCIAL SECURITY ⃞ UnKnown
NUMBER (See instructions for 9 B on Page 3)
A, PARENT/FATHER’S First Full Middle Name Last
NAME
10
B,PARENT / FATHER’S SOCIAL SECURITY ⃞ UnKnown
NUMBER (See intructions 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 card before?
⃞ Yes (If” yes” answer question 12-13) ⃞ No ⃞ Don’t Know (If “don’t know” skip to question 14.)
12 Name Show on the most recent Social Security First Full Middle Name Last
card issued for the person listed in item 1
Enter any different date of birth if used on an earlier application for a card _______________________________
13 MM/DD/YYYY
TODAY’S __________________ DAYTIME PHONE _____________________ ________________________
DATE MM/DD/YYYY NUMBER Area Code Number
14 15
Street Addres , Apt.No., PO Box, Rural Route No.
MAILING ADDRESSS
16 (Do Not Abbreviature) City State/Foreingn 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, and it is true and correct to the best of my knowledge.
17
YOUR SIGNATURE YOUR RELATIONSHIP TO THE PERSON IN ITEM 1 IS.
_______________________ 18 ⃞ Self ⃞ Natura Or ⃞ Legal ⃞ Other ___________
. Adoptive parent Guardian (Specity)
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
ITERVIEW
DATE
DCL DATE
