Fillable Form SS-5-FS (11-2019) UF: Applying for a Social (U.S. Social Security Administration)

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Form SS-5-FS (11-2019) UF: Applying for a Social (U.S. Social Security Administration)

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Application for a Social Security Card
Applying for a Social Security Card is free!
USE THIS APPLICATION TO:
• Apply for an original Social Security card
• Apply for a replacement Social Security card
• Change or correct information on your Social Security number record
IMPORTANT: You MUST provide a properly completed application and the required evidence before we can process
your 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. We will return any documents submitted with your application. For assistance, contact any U.S. Social
Security office or your Federal Benefits Unit. For a complete list of Federal Benefits Units and contact information, visit
www.socialsecurity.gov/foreign
.
Original Social Security Card
To apply for an original card, you must provide at least two documents to prove age, identity, and U.S. citizenship or
current lawful, work-authorized immigration status. If you are not a U.S. citizen and do not have Department of
Homeland Security (DHS) work authorization, you must prove that you have a valid non-work reason for requesting a
card. See page 2 for an explanation of acceptable documents.
NOTE: If you are age 12 or older and have never received a Social Security number, you must apply in person.
Replacement Social Security Card
To apply for a replacement card, you must provide one document to prove your identity. If you were born outside the
U.S., you must also provide documents to prove your U.S. citizenship or current lawful, work-authorized status. See
page 2 for an explanation of acceptable documents.
Changing Information on Your Social Security Record
To change the information on your Social Security number record (i.e., a name or citizenship change, or corrected
date of birth), you must provide documents to prove your identity, support the requested change, and establish the
reason for the change. For example, you may provide a birth certificate to show your correct date of birth. A
document supporting a name change must be recent and identify you by both your old and new names. If the name
change event occurred over two years ago or if the name change document does not have enough information to
prove your identity, you must also provide documents to prove your identity in your prior name and/or in some cases
your new legal name. If you were born outside the U.S., you must provide a document to prove your U.S. citizenship
or current lawful, work-authorized status. See page 2 for an explanation of acceptable documents.
LIMITS ON REPLACEMENT SOCIAL SECURITY CARDS
Public Law 108-458 limits the number of replacement Social Security cards you may receive to 3 per calendar year
and 10 in a lifetime. Cards issued to reflect changes to your legal name or changes to a work authorization legend do
not count toward these limits. We 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 contact any U.S.
Social Security office or your Federal Benefits Unit. For a complete list of Federal Benefits Units and contact
information, visit www.socialsecurity.gov/foreign
.
Form SS-5-FS (11-2019) UF
Discontinue Prior Editions
SOCIAL SECURITY ADMINISTRATION
Page 1 of 5
OMB No. 0960-0066
EVIDENCE DOCUMENTS
The following lists are examples of the types of documents you must provide with your application and are not all
inclusive. Contact any U.S. Social Security office or your Federal Benefits Unit 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. Visit any U.S. Social Security office or your
Federal Benefits Unit and they will make certified copies of your original documents. Do not mail your
original documents to the Social Security Administration in Baltimore, Maryland.
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), your foreign passport, foreign
driver's license or foreign ID card 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.
Page 2 of 5
Form SS-5-FS (11-2019) UF
HOW TO COMPLETE THIS APPLICATION
Complete and sign this application LEGIBLY using ONLY black or blue ink on the attached or downloaded
form using only 8 ½” x 11” (or A4, 8.25” x 11.7”) paper.
GENERAL: Items on the form are self-explanatory or are discussed below. The numbers match the numbered items
on the form. If you are completing this form for someone else, please complete the items as they apply to that person.
4. Show the month, day, and full (4 digit) year of birth; for example, “1998” for year of birth.
5. If you check “Legal Alien Not Allowed to Work” or “Other,” you must provide a document from a U.S.
Federal, State, or local government agency that explains why you need a Social Security number and
that you meet all the requirements for the U.S. government benefit. NOTE: Most agencies do not
require that you have a Social Security number. Contact us to see if your reason qualifies for a
Social Security number.
6., 7. Providing race and ethnicity information is voluntary and is requested for informational and
statistical purposes only. Your choice whether to answer or not does not affect decisions we make
on your application. If you do provide this information, we will treat it very carefully.
9.B.,10.B. If you are applying for an original Social Security card for a child under age 18, you MUST
show the parents' Social Security numbers unless the parent was never assigned a Social
Security number. If the number is not known and you cannot obtain it, check the
“unknown” box.
13. If the date of birth you show in item 4 is different from the date of birth currently shown on your
Social Security record, show the date of birth currently shown on your record in item 13 and provide
evidence to support the date of birth shown in item 4.
16. Show an address where you can receive your card.
17. WHO CAN SIGN THE APPLICATION? If you are age 18 or older and are physically and mentally
capable of reading and completing the application, you must sign in item 17. If you are under age
18, you may either sign yourself, or a parent or legal guardian may sign for you. If you are over age
18 and cannot sign on your own behalf, generally a legal guardian, parent, or close relative may sign
for you. If you cannot sign your name, you should sign with an "X” mark and have two people sign as
witnesses in the space beside the mark. Please do not alter your signature by including additional
information on the signature line as this may invalidate your application. Contact us if you have
questions about who may sign your application.
HOW TO SUBMIT THIS APPLICATION
You can mail this signed application or take this signed application with your documents to any U.S. Social Security
office or your Federal Benefits Unit. If you are a military dependent or a U.S. citizen working on a U.S. military post,
you may also go to the Post Adjutant or Personnel Office. If you do not want to mail your original documents, take
them along with this application to one of the offices listed above. The people there will make certified copies of your
original documents and mail them to the Social Security Administration along with this application. Do not mail your
original documents to the Social Security Administration in Baltimore, Maryland.
Page 3 of 5
Form SS-5-FS (11-2019) UF
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 item 5 for more information.
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.
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
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.
Page 4 of 5Form SS-5-FS (11-2019) UF
Paperwork Reduction Act Statement:
Sections 205(c) and 702 of the Social Security Act, as amended, allow us to collect this information. Furnishing us
this information is voluntary. However, failing to provide all or part of the information may prevent us from assigning
you a Social Security number (SSN) and issuing you a new or replacement Social Security card.
We will use the information to assign you an SSN and issue you a new or replacement Social Security card. We may
also share your information for the following purposes, called routine uses:
• To Federal, State, and local entities to assist them with administering income maintenance and health
maintenance programs, when a Federal statute authorizes them to use the SSN; and,
• To the Department of State for administering the Social Security Act in foreign countries through its
facilities and services.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example,
where authorized, we may use and disclose this information in computer matching programs, in which our records are
compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment
of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0058, entitled
Master Files of Social Security Number (SSN) Holders and SSN Applications, as published in the Federal Register
(FR) on December 29, 2010, at 75 FR 82121. Additional information, and a full listing of all or our SORNs, is available
on our website at www.ssa.gov/privacy.
Unknown
Unknown
7
Social Security number previously assigned to the person
listed in item 1
2
YOUR SIGNATURE
18
17
16
TODAY'S
DATE
1514
13
12
11
10
9
8
3
5
6
4
1
Application for a Social Security Card
OMB No. 0960-0066
NAME
TO BE SHOWN ON CARD
First
FULL NAME AT BIRTH
IF OTHER THAN ABOVE
First Full Middle Name Last
OTHER NAMES USED
PLACE
OF BIRTH
(Do Not
Abbreviate)
City State or Foreign Country
Office
Use
Only
FCI
DATE OF
BIRTH
MM/DD/YYYY
CITIZENSHIP
(Check One)
U.S.
Citizen
Legal Alien
Allowed To Work
Legal Alien Not Allowed To Work
(See Instructions On Page 3)
Other (See Instructions
On Page 3)
ETHNICITY
Are You Hispanic or Latino?
(Your Response is
Voluntary)
Yes No
RACE
Select One or More
(Your Response
is Voluntary)
Native
Hawaiian
American
Indian
Other Pacific
Islander
Alaska
Native
Black/African
American
White
Asian
SEX
Male Female
First Full Middle Name Last
B. PARENT/ MOTHER'S SOCIAL SECURITY
NUMBER (See instructions for 9 B on Page 3)
A. PARENT/ FATHER'S
NAME
First Full Middle Name Last
B. PARENT/ FATHER'S SOCIAL SECURITY
NUMBER (See instructions 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 questions 12-13)
No Don't Know (If "don't know," skip to question 14.)
Name shown on the most recent Social Security
card issued for the person listed in item 1
First
Full Middle Name Last
Enter any different date of birth if used on an earlier application for a card
MM/DD/YYYY
MM/DD/YYYY
DAYTIME PHONE
NUMBER
Area Code Number
MAILING ADDRESS
(Do Not Abbreviate)
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, and it is true and correct to the best of my knowledge.
YOUR RELATIONSHIP TO THE PERSON IN ITEM 1 IS:
Self
Natural Or
Adoptive Parent
Legal
Guardian
Other
(Specify)
Full Middle Name Last
A. PARENT/ MOTHER'S
NAME AT HER BIRTH
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
Page 5 of 5Form SS-5-FS (11-2019) UF
Discontinue Prior Editions
SOCIAL SECURITY ADMINISTRATION
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