2. Signture of Witness
Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the individual must sign below, giving their full addresses.
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. I understand that anyone who knowingly
gives a false or misleading statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be sent to prison, or may face other penalties, or both.
SIGNATURE OF PERSON MAKING STATEMENT
Tele
hone Numbe
ncl
de
rea
ode
-
( ) -
Signature (First name, middle initial, last name) (Write in ink)
SIGN
HERE
Date (Month, day, year)
Mailin
Add
ess
mber and street,
t.
o.,P.O.Bo
,
ral
o
te
ZIP Code
1. Signture of Witness
Address (Number and street, City, State, and ZIP Code )
Cit
and State
dd
ess
mber and street,
it
, State, and Z
P
ode
Paperwork Reduction Act Statement - 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 15 minutes to read the instructions,
gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social
Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate a bove to: SSA, 6401
Security Boulevard, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
Privacy Act Statement
Collection and Use of Personal Information
Public Law 110-328 and section 1631(e) of the Social Security Act, as amended, authorize us to collect this information. The information you
rovide will be used to determine if you have made a good faith effort to pursue U.S. Citizenship, so that we may make a decision on
additional Supplemental Security Income (SSI) benefits.
The information you furnish on this form is voluntary. However, failure to provide the requested information will prevent us from making a
timely decision on your benefits.
We generally use the information you supply for the purpose of determining eligibility for benefits. However, we may use it for the
administration and integrity of Social Security programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:
1.To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage, including the
U.S. Citizenship and Immigration Service in order to verify information provided;
2.To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability
Office and Department of Veterans' Affairs);
3.To make determinations for eligibility in similar health and income maintenance programs at the Federal, state, and local level; and
4.To facilitate statistical research, audit or investigative activities necessary to assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by
other Federal, state, or local government agencies. Information from these matching programs can be used to establish or verify a person's
eligibility for Federally funded or administered benefit programs and for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and systems, is available on-line at www.ssa.gov or
at your local Social Security office.
