G$)99998771445956044087

20152795600001U(D

'3pr7nB
'3pr7nB
4r=;4r=;
2/B3=2015/10/28
2/B3=2015/10/28
=4 'EF
=4 'EF
D=20152795600001U(D
D=G$)99998771445956044087

F=r; Appr=D32
(=17/: (31Cr7BG A2;7n7ABr/B7=n
OMB $=. 0960-0760
A0/ho-iza/ion fo- /he So ia( Se 0-i/y Ad)ini./-a/ion (SSA) To Re(ea.e So ia(
Se 0-i/y N0)be- (SSN) Ve-ifi a/ion
Pr7nB32 $/;3:
D/B3 =4 B7rB6:
(=17/: (31Cr7BG $C;03r:
E/nB B67A 7n4=r;/B7=n r3:3/A32 031/CA3 /; 1=n2C1B7n5 B63 4=::=E7n5 0CA7n3AA Br/nA/1B7=n:
App:G7n5 4=r / n3E A;3r71/n EFpr3AA C/r2
'3/A=n (A) 4=r CA7n5 CB(V: (P:3/A3 A3:31B /:: B6/B /pp:G)
M=rB5/53 (3rD713
- B/n97n5 (3rD713
B/195r=Cn2 C6319

"713nA3 '3qC7r3;3nB

Cr327B C6319
OB63r
E7B6 B63 4=::=E7n5 1=;p/nG ("B63 C=;p/nG"):
C=;p/nG $/;3:
A;3r71/n EFpr3AA
C=;p/nG A22r3AA:
4315 (. 2700 ,. (/:B "/93 C7BG, U) 84102
/CB6=r7H3 B63 (=17/: (31Cr7BG A2;7n7ABr/B7=n B= D3r74G ;G n/;3 /n2 (($ B= B63 C=;p/nG /n2/=r B63
C=;p/nG'A A53nB, 74 /pp:71/0:3, 4=r B63 pCrp=A3 723nB74732.
)63 n/;3 /n2 /22r3AA =4 B63 C=;p/nG'A A53nB 7A:
"3F7A$3F7A '7A9 (=:CB7=nA
6601 P/r9 =4 C=;;3r13 B=1/ '/B=n, F" 33487
/; B63 7n27D72C/: B= E6=; B63 (=17/: (31Cr7BG nC;03r E/A 7AAC32 =r B63 p/r3nB =r :35/: 5C/r27/n =4 / ;7n=r,
=r B63 :35/: 5C/r27/n =4 / :35/::G 7n1=;p3B3nB /2C:B. 231:/r3 /n2 /447r; Cn23r B63 p3n/:BG =4 p3r8CrG B6/B B63
7n4=r;/B7=n 1=nB/7n32 63r37n 7A BrC3 /n2 1=rr31B. /19n=E:3253 B6/B 74 ;/93 /nG r3pr3A3nB/B7=n B6/B 9n=E 7A
4/:A3 B= =0B/7n 7n4=r;/B7=n 4r=; (=17/: (31Cr7BG r31=r2A, 1=C:2 03 4=Cn2 5C7:BG =4 / ;7A23;3/n=r /n2 47n32 Cp
B= $5,000.
Thi. on.en/ i. va(id on(y fo- 90 day. f-o) /he da/e .igned, 0n(e.. indi a/ed o/he-wi.e by /he individ0a(
na)ed above. If yo0 wi.h /o hange /hi. /i)ef-a)e, fi(( in /he fo((owing:
Thi. on.en/ i. va(id foday. f-o) /he da/e .igned.
(75n/BCr3
D/B3 (75n32
'3:/B7=nA67p (74 n=B B63 7n27D72C/: B= E6=; B63 (($ E/A 7AAC32):
Con/a / info-)a/ion of individ0a( .igning a0/ho-iza/ion:
Add-e..
Ci/y/S/a/e/Zi,
Phone N0)be-

(P(ea.e ini/ia(.)

F=r; SSA-89 (06-2013)

C=nB7nC32 =n r3D3rA3 A723

P/53 3 =4 4

G$)99998771445956044087
20152795600001U(D

'3pr7nB
'3pr7nB
4r=;4r=;
2/B3=2015/10/28
2/B3=2015/10/28
=4 'EF
=4 'EF
D=20152795600001U(D
D=G$)99998771445956044087

P-iva y A / S/a/e)en/
((A 7A /CB6=r7H32 B= 1=::31B B63 7n4=r;/B7=n =n B67A 4=r; Cn23r (31B7=nA 205 /n2 1106 =4 B63 (=17/: (31Cr7BG
A1B /n2 B63 Pr7D/1G A1B =4 1974 (5 U.(.C. I 552/). ,3 n332 B67A 7n4=r;/B7=n B= pr=D723 B63 D3r7471/B7=n =4 G=Cr
n/;3 /n2 (($ B= B63 C=;p/nG /n2/=r B63 C=;p/nG'A A53nB n/;32 =n B67A 4=r;. G7D7n5 CA B67A 7n4=r;/B7=n 7A
D=:CnB/rG. H=E3D3r, E3 1/nn=B 6=n=r G=Cr r3qC3AB B= r3:3/A3 B67A 7n4=r;/B7=n E7B6=CB G=Cr 1=nA3nB. ((A ;/G
/:A= CA3 B63 7n4=r;/B7=n E3 1=::31B =n B67A 4=r; 4=r AC16 pCrp=A3A /CB6=r7H32 0G :/E, 7n1:C27n5 B= 3nACr3 B63
C=;p/nG /n2/=r C=;p/nG'A A53nB'A /ppr=pr7/B3 CA3 =4 B63 (($ D3r7471/B7=n A3rD713.
Pa,e-wo-k Red0 /ion A / S/a/e)en/ - )67A 7n4=r;/B7=n 1=::31B7=n ;33BA B63 r3qC7r3;3nBA =4 44 U.(.C. I
3507, /A /;3n232 0G A31B7=n 2 =4 B63 P/p3rE=r9 '32C1B7=n A1B =4 1995. .=C 2= n=B n332 B= /nAE3r B63A3
qC3AB7=nA Cn:3AA E3 27Ap:/G / D/:72 O44713 =4 M/n/53;3nB /n2 BC253B 1=nBr=: nC;03r. ,3 3AB7;/B3 B6/B 7B E7::
B/93 /0=CB 3 ;7nCB3A B= 1=;p:3B3 B63 4=r;. Yo may send comments on o r time estimate above to: SSA, 6401
Sec rity Blvd., Baltimore, MD 21235-6401. Send to this address only comments relating to our time estimate,
not the completed form.
)EA' OFF
NOTICE TO NUMBER HOLDER
)63 C=;p/nG /n2/=r 7BA A53nB 6/D3 3nB3r32 7nB= /n /5r33;3nB E7B6 ((A B6/B, /;=n5 =B63r B67n5A, 7n1:C23A
r3ABr71B7=nA =n B63 4CrB63r CA3 /n2 27A1:=ACr3 =4 ((A'A D3r7471/B7=n =4 G=Cr (($. )= D73E / 1=pG =4 B63 3nB7r3
;=23: /5r33;3nB, D7A7B 6BBp://EEE.AA/.5=D/10AD/2=1A/(/;p:3UA3rA5r33;3nB.p24

F=r; SSA-89 (06-2013)

P/53 4 =4 4