Social Security Application – Fill Out and Use This PDF

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.

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 does not affect decisions on your application. We request this information for research and statistical purposes, to ensure all our customers receive fair and equal treatment.

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.

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

Sections 205 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 and issuing you a new or replacement Social Security card.

We will use the information you provide to issue you a 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 Social Security number; and

•To student volunteers, persons working under a personal services contract, and others when they need access to information in our records in order to perform their assigned agency duties.

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 Notices (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 of our SORNs, is available on our website at www.ssa.gov/privacy.

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 between 5 and 60 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED

FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also 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 regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

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.