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Form SSA-754-F5 (06-2019)
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 els to do so, commits
a crime and may be sent to prison, or may face other penalties, or both.
SIGNATURE OF APPLICANT (First name, middle initial, last name)
DATE (Month, day, year)
MAILING ADDRESS (Number and Street, Apt. No., P.O. Box or Rural Route)
TELEPHONE NUMBER(S) at which you may
be called during the day (including area code)
County (if any in which you now live)
State
City
Zip Code
Witnesses are required only if this application has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the applicant must sign below, giving their full addresses.
1. SIGNATURE OF WITNESS 2. SIGNATURE OF WITNESS
ADDRESS (Number and Street, City, State, and Zip Code) ADDRESS (Number and Street, City, State, and Zip Code)
Privacy Act Notice: Section 216(h), of the Social Security Act, as amended, authorizes us to collect this information. We will use
this information to make a determination on your claim. Furnishing us this information is voluntary. However, failure to provide all
or part of the information could prevent us from making an accurate and timely decision on your benefit eligibility. We rarely use
the information you supply for any purpose other than for making a determination relating to benefit eligibility. 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; 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 and improvement of Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to
Social Security). 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. A complete list of routine uses for this information is available in Systems of
Records Notices entitled, Claims Folder Record, 60-0089 and Master Beneficiary Record, 60-0090. These notices, additional
information regarding this form, and information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security office.
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 30 minutes to read the instructions, gather the facts,
and answer the questions. SEND OR BRING 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 above to: SSA, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
