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Get SSA SS-5 2006

16 YOUR SIGNATURE YOUR RELATIONSHIP TO THE PERSON IN ITEM 1 IS Self Natural Or Adoptive Parent Legal Guardian Other Specify DO NOT WRITE BELOW THIS LINE FOR SSA USE ONLY NPN PBC DOC EVI EVA EVC NTI CAN PRA EVIDENCE SUBMITTED NWR ITV DNR UNIT SIGNATURE AND TITLE OF EMPLOYEE S REVIEWING EVIDENCE AND/OR CONDUCTING INTERVIEW DCL Form SS-5 05-2006 ef 05-2006 Destroy Prior Editions Page 5. SOCIAL SECURITY ADMINISTRATION Application for a Social Security Card Form Approved OMB No* 0960-0066 First Full Middle Name Last NAME TO BE SHOWN ON CARD FULL NAME AT BIRTH IF OTHER THAN ABOVE OTHER NAMES USED Street Address Apt. No* PO Box Rural Route No* MAILING ADDRESS State City ZIP Code - Do Not Abbreviate Legal Alien Allowed To Work CITIZENSHIP SEX Male RACE/ETHNIC DESCRIPTION Asian Asian-American or Pacific Islander DATE OF Month Day Year BIRTH A. MOTHER S NAME AT HER BIRTH Allowed To Work See Instructions On Page 2 Other See Instructions On Page 2 PLACE U*S* Citizen Check One Check One Only - Voluntary Female North American Indian or Alaskan Native Black Not Hispanic White Office Use Only State or Foreign Country B. MOTHER S SOCIAL SECURITY NUMBER See instructions for 8B on Page 2 FCI Last Name At Her Birth A. FATHER S NAME Has the applicant or anyone acting on his/her behalf ever filed for or received a Social Security number card before Don t Know If don t know Yes If yes answer questions 11-13. No If no go on to question 14. Enter the Social Security number previously assigned to the person listed in item 1. Enter the name shown on the most recent Social Security card issued for the person listed in item 1. Enter any different date of birth if used on an earlier application for a card. 14 TODAY S go on to question 14. 15 DAYTIME PHONE NUMBER Area Code Number 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. SOCIAL SECURITY ADMINISTRATION Application for a Social Security Card Form Approved OMB No* 0960-0066 First Full Middle Name Last NAME TO BE SHOWN ON CARD FULL NAME AT BIRTH IF OTHER THAN ABOVE OTHER NAMES USED Street Address Apt. No* PO Box Rural Route No* MAILING ADDRESS State City ZIP Code - Do Not Abbreviate Legal Alien Allowed To Work CITIZENSHIP SEX Male RACE/ETHNIC DESCRIPTION Asian Asian-American or Pacific Islander DATE OF Month Day Year BIRTH A. No* PO Box Rural Route No* MAILING ADDRESS State City ZIP Code - Do Not Abbreviate Legal Alien Allowed To Work CITIZENSHIP SEX Male RACE/ETHNIC DESCRIPTION Asian Asian-American or Pacific Islander DATE OF Month Day Year BIRTH A. MOTHER S NAME AT HER BIRTH Allowed To Work See Instructions On Page 2 Other See Instructions On Page 2 PLACE U*S* Citizen Check One Check One Only - Voluntary Female North American Indian or Alaskan Native Black Not Hispanic White Office Use Only State or Foreign Country B. MOTHER S NAME AT HER BIRTH Allowed To Work See Instructions On Page 2 Other See Instructions On Page 2 PLACE U*S* Citizen Check One Check One Only - Voluntary Female North American Indian or Alaskan Native Black Not Hispanic White Office Use Only State or Foreign Country B. MOTHER S SOCIAL SECURITY NUMBER See instructions for 8B on Page 2 FCI Last Name At Her Birth A. FATHER S NAME Has the applicant or anyone acting on his/her behalf ever filed for or received a Social Security number card before Don t Know If don t know Yes If yes answer questions 11-13. .

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