Application for Social Security

Fill only as marked in yellow

All areas can be and should be filled before printing

1.) Name First or given name Full Middle Name if none leave blank Last or Family name

3.) Place of Birth City or Province where you were born Foreign Country name

4.) Date of Birth Month/ day/ Year example: Dec 25 1995

9A.) Mothers name (When she was born) First (given) Middle ( if none leave blank) last ( family
name)

10A.) Fathers Name First (given) Middle ( if none leave blank) last ( family name)

14.) Todays date Month / day/ year example: April 10 1995

16.) Mailing address only enter the room number of your housing in this area beside APT#

Print the application at this time

17.) Your Signature Sign the same way you did on passport. Must be in ink hand signed

CONTROL NUMBER This is the number listed on the online application

 Control Number
SOCIAL SECURITY ADMINISTRATION Form Approved
Application for a Social Security Card OMB No. 0960-0066

NAME First Full Middle Name Last

TO BE SHOWN ON CARD
FULL NAME AT BIRTH First Full Middle Name Last
1 IF OTHER THAN ABOVE

OTHER NAMES USED

2 Social Security number previously assigned to the person

listed in item 1 ó ó
PLACE Office DATE
Use
3 OF BIRTH Only 4 OF
(Do Not Abbreviate) City State or Foreign Country FCI BIRTH MM/DD/YYYY

Legal Alien Legal Alien Not Allowed Other (See

5 CITIZENSHIP U.S. Citizen ■ Allowed To To Work(See Instructions On
(Check One) Work Instructions On Page 3) Page 3)

ETHNICITY RACE Native Hawaiian American Indian Other Pacific

Islander
6 Are You Hispanic or Latino?
(Your Response is Voluntary) 7 Select One or More
(Your Response is Voluntary)
Alaska Native Black/African White
Asian American
Yes No

8 SEX Male Female

First Full Middle Name Last
A. PARENT/ MOTHER'S
NAME AT HER BIRTH
9 B. PARENT/ MOTHER'S SOCIAL
SECURITY NUMBER (See instructions for 9 B on Page 3)
ó ó ■ Unknown

First Full Middle Name Last

A. PARENT/ FATHER'S
NAME
10 B. PARENT/ FATHER'S SOCIAL
SECURITY NUMBER (See instructions for 10B on Page 3)
ó ó ■ Unknown

Has the person listed in item 1 or anyone acting on his/her behalf ever filed for or received a Social Security number
11 card 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 card issued for the person
listed in item 1 NA
Enter any different date of birth if used on an
13 earlier application for a card MM/DD/YYYY
TODAY'S
14 DATE MM/DD/YYYY
15 DAYTIME PHONE
NUMBER
865
Area Code Number
Street Address, Apt. No., PO Box, Rural Route No.
MAILING ADDRESS
16 City State/Foreign Country ZIP Code
(Do Not Abbreviate)
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 to my knowledge.
17 YOUR SIGNATURE
18
YOUR RELATIONSHIP TO THE PERSON IN ITEM 1 IS:
Natural Or
■ Self Legal Guardian Other Specify
Adoptive Parent

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) Destroy Prior Editions Page 5
 Form Approved
Social Security Administration OMB No. 0960-0778

Notification of a Social Security Number (SSN)

to an Employer for Wage Reporting Purposes

A. Employer Information

Employer's Name:

Street:
Employer's Address:
City: State: Zip:

Employer's Identification Number (EIN):

B. To be completed by the SSN applicant

I request that SSA notify my employer of my SSN

upon assignment.
Printed Name:

Signature: Date:

(MM/DD/YYYY)

C. For SSA use only

An SSN has been assigned and a Social Security card was mailed to the following person who
requested we notify you directly of the SSN.

First Name:

Middle Name:

Last Name:

Social Security Number:

NOTE: This notification may only be used for original SSN applications when SSA has not yet
assigned an SSN.

Form SSA-132 (05-2010) 1