Form SSA-L996 (01-2020)
Discontinue Prior Editions
Social Security AdministrationPage 1 of 1
Social Security Number Record
Request for Extract or Photocopy
INSTRUCTIONS: Print or type all data. Sign in ink. Allow 4 to 6 weeks for a reply.
I hereby request an extract or photocopy of my application(s) for a social security number. To establish my identity and to verify
my social security number, I am furnishing my full identifying information, as follows.
Social Security Number (if known) Full Name Used
Name Shown on Last Social Security Card (if different from full name now used)
Full Name at Birth
Date of Birth (MM/DD/YYYY)
Place of Birth (city, county, and state or foreign country)
Gender
Male
Female
Full Maiden Name of Mother (whether living or deceased)
Full Name of Father (whether living or deceased)
PENALTY STATEMENT (read before signing) I am the person to whom this record pertains and I understand that to knowingly
and willfully petition or acquire information from a person's Social Security record under false pretenses is a criminal offense
subject to a $5,0000 fine.
Signature (do not print unless this is your usual signature)
Date
Street Address City, State, and ZIP Code
NOTE: A printed signature or a signature by mark (X) must be witnessed below by two adults.
1. Signature
Street Address
City, State, and ZIP Code
2. Signature
Street Address
City, State, and ZIP Code
Mail to: DEBS Enumeration Unit
PO Box 33000
Baltimore, MD 21290-3000
