Copyright 2010

YOUR SECOND SOCIAL

SECURITY NUMBER
GUIDE
All rights rsr!"# No p$rt o% this p&'li($tio) *$y '
rpro"&("+ stor" or *$i)t$i)" i) $ rtri!$l syst*
$)" or tr$)s*itt" i) $)y %or* or 'y $)y *$)s+
l(tro)i(+ *(h$)i($l+ photo(opyi)g+ r(or"i)g+ or
othr,is ,hthr or )ot this *$)s prs)tly -isti)g
or sh$ll -ist i) th %&t&r+ ,itho&t th prior ,ritt)
pr*issio) #
This p&'li($tio) is "sig)" to pro!i" $((&r$t $)"
$&thorit$ti! i)%or*$tio) i) rg$r" to th s&'.(t
*$ttr (o!r" hri)# It is sol" ,ith th &)"rst$)"i)g
th$t th p&'lishr is )ot )g$g" i) r)"ri)g lg$l+
$((o&)ti)g+ or othr pro%ssio)$l sr!i(# I% lg$l $"!i(
or othr -prt $ssist$)( is r/&ir"+ th sr!i(s o% $
(o*pt)t pro%ssio)$l prso) sho&l" ' so&ght#
TABLE OF CONTENTS
INTRODUCTION PAGE 2
PART ONE
SECTION ONE
How To Understand Your Credit
Reort And Dete!t I" Your So!ia#
Se!urit$ Nu%&er Is Bein' Used
SECTION T(O
How To A#$ For Your Se!ond
So!ia# Se!urit$ Nu%&er
PAGE )
PAGE *)
PART T(O
SECTION ONE
How To Re!ei+e And Proer#$ Use
Your T,ird Nu%&er Otion
SECTION T(O
For%s Ne!essar$ To A#$ For An
E%#o$er Identi"i!ation Nu%&er And
Ta-a$er Identi"i!ation Nu%&er
PAGE 2*
PAGE 2.
PART THREE PAGE ))
For%s Use"u# In Disutin'
Ne'ati+e Credit
PART FOUR PAGE /.
Co%#i%entar$ Listin' O" O+er
*00 Ban12 Retai#2 3 Gas
Credit Co%anies
2
When Kevin and Mary were newlyweds, they went through rough times
and had trouble paying their bills. They received many credit card offers and
quickly succumbed to the allure of easy credit. Kevin and Mary wanted to buy
more things than they could afford and charging was an easy way of getting what
they wanted. ears later, Kevin was forced to take a pay cut and the couples
income was severely cut. With too much credit card debt and a lower monthly
income, Kevin and Mary again e!perienced difficulty paying their bills. "oon their
financial trouble became serious. #owever, with the help of $onsumer $redit
$ounseling "ervice %$$$"& , Kevin and Mary were eventually able to recover
from their money problems and pay off their debts. $$$" is a national nonprofit
organi'ation with local chapters around the country that help consumers in
financial difficulty.
Kevin and Mary(s credit histories were seriously damaged but they
wanted to buy a home) in order to do so they needed to rebuild their credit. *s
part of their rebuilding process, they requested copies of their credit report from
each of the big three credit bureaus. This was done in order to correct and
identify any problems in their credit files. #owever, early in the process
they became frustrated because of inaccurate information. Mary and Kevin were
successful in getting the errors deleted from their credit file but often the
misinformation would reappear.
This couple(s problems are not unusual. Many consumers ruin their
credit by taking on more debt than they can handle. *s a result, they must
face the challenge of correcting any problems in their credit records and
rebuilding their credit in order to borrow money at reasonable terms+a
process that can take years. ou are responsible for your credit record
problems, but not responsible for misinformation. ,erhaps the misinformation
results from debts which were paid but are listed as unpaid. Many consumers
learn that addressing credit record problems sometimes requires patience and
perseverance. Within this booklet you will learn how to correct credit record
errors and inaccuracies and how to deal with credit record omissions. ou will
also find out how to request your 2
nd
"ocial "ecurity -umber. The story that
you(ve .ust read is only one scenario that may result in a request for a 2
nd
"ocial "ecurity -umber, but the reasons for requesting are as many as
their are stars in the sky. Many consumers feel - disadvantaged or subjected
to negative economical or personal hardship- due to their credit file being tied to
their "ocial "ecurity -umber. They are unable to obtain credit and for that
reason we have devised a simple set of guidelines to use in your petition for a
2
nd
"ocial "ecurity -umber which can accommodate any situation.
-o firm number e!ists to show the percentage of credit files that have
problems. /uring the early 0112(s, estimates ran as high as 405 but given
industry efforts to reduce that rate, the percentage is probably lower today. 3n
addition, some of the amendments to the 4$5* are intended to further reduce
the incidence of credit record problems. 5ealistically however, given that the
3
industry collects more than 2.5 billion pieces of credit-related information
each month and generates more than 600 million credit reports on
close to 200 million consumers every year, there are bound to be errors
in some credit files. Credit bureaus do make mistakes. Also, sometimes
creditors and other information providers give credit bureaus incorrect
information. Therefore, to protect yourself, read your credit report
carefully! We have supplied you with some tools to assist you with this
sometimes frustrating and confusing task which will make it simpler.
Co%%on Credit Re!ord Errors6
Information is commingled. Your credit record includes information for
someone with a name similar or identical to yours.
The name of a former spouse appears on your credit record.
Your name is misspelled, your address is wrong or your Social Security
Number is incorrect.
uplicate accounts show up.
!ccount information is inaccurate or incomplete. "or e#ample, information for
an account shows that you were delin$uent for several months a year ago, but
fails to show that you caught up and have paid on time for the past nine
months. %ther problems could include incorrect account balances and
reporting paid-of or closed accounts as open.
%utdated information is included. In most cases, a credit reporting agency is
legally permitted to maintain and report negative account information about a
consumer for &'( years and ban)ruptcies for &*+( years.
!ccount information does not relate to you.
,nauthori-ed in$uiries are listed.
There is a failure to show that a ta# lien has been released.
6
PART ONE
SECTION ONE
How To Understand Your Credit Reort
And Dete!t I" Your So!ia# Se!urit$
Nu%&er Is Bein' Used
7
Dealing with Inaccurate or Outdated Information That
Reappears in Your redit Record
T,e FCRA now re7uires !redit reortin' a'en!ies to %aintain 8
reasona&#e ro!edures desi'ned to re+ent t,e reaearan!e o" de#eted
in"or%ation98 Be!ause t,e #aw does not de"ine 8 reasona&#e ro!edures28
,owe+er2 t,e a!tua# i%a!t o" t,is new ro+ision re%ains to &e seen9 On t,e
ot,er ,and2 t,e re+ised #aw a#so states t,at &e"ore de#eted in"or%ation !an
&e reinserted into $our !redit "i#e2 t,e ro+ider o" t,e in"or%ation %ust !erti"$
in writin' t,at t,e in"or%ation is indeed !o%#ete and a!!urate9 Furt,er%ore2
t,e !redit &ureau %ust noti"$ $ou in writin'2 wit,in "i+e &usiness da$s2 t,at
t,e in"or%ation ,as &een reinserted: ro+ide $ou t,e na%e2 address2 and
,one nu%&er2 i" 8reasona&#$ a+ai#a&#e28 o" t,e in"or%ation ro+ider: and
e-#ain $our ri',t to add a state%ent to $our !redit "i#e a&out t,e disuted
in"or%ation9
!hen a redit "ureau#s In$estigation Does %ot orrect a
redit Record &roblem
It;s ossi&#e t,at a !redit &ureau;s in+esti'ation wi## "ind t,at t,e
in"or%ation $our are disutin' is a!tua##$ !orre!t9 I" t,is o!!urs2 $ou ,a+e
se+era# otions9 One otion is to #o!ate new or additiona# do!u%entation
t,at ,e#s suort $our !ase9 <a1e !oies o" an$ su!, do!u%entation2 write
t,e !redit reortin' a'en!$2 and sta#e e+er$t,in' to'et,er9 Be sure to %a1e
a !o$ o" t,e #etter "or $our "i#es and send t,e %ateria#s &$ !erti"ied %ai#
wit, a re7uest "or a return re!eit9 Anot,er otion is to !onta!t t,e ro+ider
o" t,e in"or%ation $ou are disutin' and as1 t,at t,e$ !orre!t t,e ro&#e%9
Preare a #etter si%i#ar to t,e one $ou %ai#ed to t,e !redit &ureau and in!#ude
wit, it !oies o" $our &a!1u in"or%ation9 In $our #etter2 as1 t,at t,e !reditor
send a !orre!tion to a## o" t,e !redit &ureaus it reorts to as we## as to $ou9
A#so2 as1 t,at t,e in"or%ation ro+ider dire!t t,ose !redit &ureaus to !orre!t
$our !redit "i#e9 To %a1e !ertain t,at t,e in"or%ation ro+ider "o##ows $our
instru!tions2 as1 to &e sent a !o$ o" t,e #etter=s> t,at it sends to ea!,
!redit &ureau9 A t,ird otion "or reso#+in' a !redit re!ord ro&#e% is to !a##
$our state attorne$ 'enera#;s o""i!e o" !onsu%er a""airs to see i" t,e$ !an
,e# $ou9 <an$ states ,a+e t,eir own !redit reortin' #aws9
!ritten 'tatement
I" a !redit &ureau noti"ies $ou t,at t,e in"or%ation $ou are disutin'
is !orre!t2 t,e$ %ust te## $ou a&out $our "ourt, otion9 Preare a written
state%ent o" no %ore t,an *00 words to disute t,e in"or%ation w,i!, !an
&e ut into $our !redit "i#e9 Use t,e state%ent to e-#ain w,$ $ou &e#ie+e t,e
in"or%ation in $our !redit "i#e is in error9 B$ #aw $our state%ent %ust
&e!o%e a er%anent art o" $our !redit "i#e and %ust &e ro+ided to an$one
w,o re+iews $our !redit re!ord9 I"
5
$ou need ,e# writin' $our state%ent2 FCRA re7uires t,at !redit reortin'
a'en!ies %a1e a sta"" erson a+ai#a&#e to assist $ou9
T,e E-erian Credit Reort
T,is reort;s strai',t"orward narrati+e "or%at %a1es it e-tre%e#$ eas$ to
read9 T,e reort !o%es wit, a rein+esti'ation re7uest "or% "or !onsu%ers w,o
"ind ro&#e%s in t,eir !redit reorts9
Consu%er ID Nu%&er
E-erian 'i+es ea!, !onsu%er an ID nu%&er t,at;s at t,e to o" t,e "irst
a'e o" t,e sa%#e reort9 Use t,is nu%&er i" $ou ,a+e to !a## or write E-erian
a&out in"or%ation in $our !redit reort9
Credit Histor$
Li1e t,e !redit reorts o" Trans Union and E7ui"a-2 E-erian;s &e'ins wit,
$our !redit ,istor$9 Credit ,istor$ in"or%ation is resented under two ,eadin's2
A!!ount and Des!rition9 T,e a!!ounts under t,e "irst ,eadin' are #isted in
a#,a&eti!a# order and in!#udes an address and an a!!ount nu%&er "or ea!,9 T,e
des!riti+e in"or%ation is to t,e ri',t o" t,e a!!ount na%e2 address2 and
nu%&er9 It in!#udes t,e date t,e a!!ount was oened2 its ter%s o" a$%ent2
w,o ,as !ontra!tua# resonsi&i#it$ "or a$in' t,e a!!ount2 t,e a!!ount;s !redit
#i%it2 and its ,i', &a#an!e9
I" t,e a!!ount is a &an1 #oan2 t,e des!riti+e in"or%ation in!#udes t,e
date t,e #oan was ta1en out2 t,e ter%s o" t,e #oan =nu%&er o" $ears to a$ it
o"">2 w,o ,as resonsi&i#it$ "or t,e #oan a$%ents2 and t,e ori'ina# a%ount o" t,e
#oan9
Ot,er A!!ount?Re#ated In"or%ation
Be#ow t,e a!!ount and des!rition in"or%ation $ou wi## "ind se+era# #ines o"
in"or%ation su%%ari@in' ea!, a!!ount;s a$%ent ,istor$2 in!#udin' w,et,er
a!!ount a$%ents are !urrent2 w,et,er a## a$%ents ,a+e &een %ade on ti%e2
t,e s!,edu#ed %ont,#$ a$%ent2 t,e "irst ti%e t,e a!!ount was reorted to
E-erian2 t,e &a#an!e due on t,e a!!ount as o" a !ertain date2 and t,e nu%&er o"
%ont,s o" a!!ount in"or%ation E-erian re+iewed9 A#so s,own in t,is se!tion o"
t,e reort are notations as to w,et,er an a!!ount was !#osed &$ t,e !onsu%er
or &$ t,e !reditor9

&ublic Record Information

E-erian is t,e on#$ &ureau o" w,i!, t,e &i' t,ree resents u&#i! re!ord
in"or%ation in t,e !redit ,istor$ se!tion o" its reort9 In "a!t2 an$ u&#i! re!ord
ite%s in $our !redit "i#e wi## &e #isted &e"ore an$ o" $our !redit a!!ounts9 T,ere
is no u&#i! re!ord in"or%ation in t,e sa%#e reort9
In(uiries T,e in7uiries se!tion o" t,e E-erian !redit reort2 8Your Credit
Histor$ (as Re+iewed B$82 "o##ows t,e !redit ,istor$ se!tion9 It #ists t,e
na%es and addresses o" !o%anies t,at as1ed to re+iew $our !redit ,istor$2 t,e
date o" t,e rre7uest2 and t,e reason "or t,e re7uest9 E-erian2 a#one o" t,e
&i' t,ree &ureaus2 ro+ides detai#ed in"or%ation re'ardin' in7uires9
Identification Information
T,e #ast art o" t,e E-erian !redit reort resents $our ersona#
identi"i!ation in"or%ation9 T,is se!tion &e'ins &$ #istin' $our na%e2 address2
So!ia# Se!urit$ nu%&er2 date o" &irt,2 and na%e o" $our souse t,is is in"or%ation
t,at $ou ro+ided E-erian w,en $ou re7uested a !o$ o" $our !redit reort9
T,ere is a#so additiona# identi"$in' in"or%ation a&out $ou ro+ided &$ E-erian;s
su&s!ri&ers9 T,at in"or%ation in!#udes $our dri+er;s #i!ense nu%&er2 !urrent and
"or%er addresses2 and e%#o$er in"or%ation9
The Trans )nion redit Report
Fi'ure )92 is a sa%#e Trans Union !redit reort9 O" t,e &i' t,ree
a'en!ies2 it is t,e %ost di""i!u#t to understand9 T,e Trans Union reort !o%es
wit, an in+esti'ation re7uest "or% t,at ser+es t,e sa%e urose as t,e E7ui"a-
resear!, re7uest "or%9 Use t,is "or% to disute in"or%ation in $our !redit reort9
Identif*ing Information
Your na%e2 So!ia# Se!urit$ Nu%&er2 !urrent address and an$ "or%er
address reorted2 $our &irt, date2 and $our ,one nu%&er wi## aear !#ose to
t,e to o" $our Trans Union Credit reort9 In"or%ation on $our !urrent and
"or%er e%#o$ers %a$ a#so aear ,ere2 a#t,ou', t,ere is no su!, in"or%ation
on t,e sa%#e reort9
7
redit +istor*
Your ,istor$ wit, !reditors w,o reort to Trans Union "o##ow t,e
identi"$in' in"or%ation9 A!!ount in"or%ation is resented under a series o"
,eadin's9 To t,e "ar #e"t under t,ese ,eadin's is t,e na%e o" t,e !reditor
reortin' to Trans Union and &e#ow t,at2 $our a!!ount nu%&er9 T,e series o"
nu%&ers and #etters to t,e i%%ediate ri',t o" ea!, !reditor;s na%e
reresents a !reditor;s su&s!ri&er !ode: $ou do not need to &e !on!erned
wit, t,ese !odes9
Be#ow $our a!!ount nu%&er is series o" #etters or !odes indi!atin'
w,ose resonsi&i#it$ it is to a$ t,e a!!ount9 Trans Union uses nine
di""erent #etters9 Readin' t,e sa%#e !redit reort2 $ou wi## note t,at %ost o"
t,e a!!ounts are desi'nated as 8I82 or indi+idua# a!!ounts9 On t,is sa%e
#ine t,ere %a$ a#so &e in"or%ation re'ardin' an$ !o##atera# t,at was used
to se!ure t,e !redit9 For e-a%#e2 on t,e sa%e !redit reort2 $ou;## note
t,at t,e Frost Ban1 Loan "or A*/2/00900 was se!ured wit, a ie!e o" rea#
estate2 8#ot )A a%ended #at98
On t,e sa%e #ine as t,e !reditor;s na%e &ut to t,e ri',t is t,e date
t,e a!!ount was oened2 t,e %ost e+er owed on t,e a!!ount2 and t,e date
t,at t,e !redit in"or%ation on t,e a!!ount was reorted to Trans Union9
Fo##owin' t,at date is a #etter =C2 F2 P2 A2 or B>2 w,i!, desi'nates t,e status
o" t,e a!!ount su!, as !#osed2 written o"" or aid o""9 Be#ow t,at &#o!1 o"
in"or%ation is t,e !redit #i%it "or t,e a!!ount and t,e date t,e a!!ount was
!#osed2 i" a#i!a&#e9 Loo1in' at t,e (e##s Far'o a!!ount on t,e sa%#e
!redit reort2 $ou wi## see t,at t,e a!!ount !redit #i%it was A)2000900 and
t,at t,e a!!ount was !#osed in .CD)9
I" $ou !ontinue readin' to t,e ri',t2 t,e &#o!1 o" in"or%ation
#a&e#ed2 present status s,ows t,e a!!ount &a#an!e as o" t,e date t,e
a!!ount in"or%ation was +eri"ied &$ Trans Union or t,e a!!ount was !#osed2
and an$ ast due a%ount as o" t,e sa%e date9 Be#ow t,at in"or%ation is
de#in7uen!$2 t,e do##ar a%ount o" t,at de#in7uen!$2 and ,ow t,e a!!ount
was &ein' aid at t,e ti%e o" t,e de#in7uen!$9
Fina##$2 &e#ow t,e de#in7uen!$ in"or%ation %a$ &e in"or%ation
des!ri&in' t,e 1ind o" !redit t,e a!!ount reresents2 "or e-a%#e6 !redit !ard2
rea# estate2 or auto%o&i#e2 &oat2 or ersona# #oan9
T,e ne-t #ar'e &#o!1 o" in"or%ation to t,e ri',t2 8Pa$%ent Pattern8
ro+ides detai#ed a$%ent ,istor$ in"or%ation "or ea!, a!!ount in $our
reort9 U to 2/ %ont,s; wort, o" in"or%ation is ro+ided9 Read t,e s$%&o#s
in t,is se!tion "ro% #e"t to ri',t9 T,e %ost !urrent in"or%ation is to t,e "ar
#e"t o" t,e to #ine9 You wi## see eit,er a nu%&er or Es as $ou read9 A *
%eans t,at $our a!!ount a$%ent t,at %ont, was on ti%e: 2 t,rou', F
indi!ate di""erent de'rees o" #ateness: E %eans t,at no in"or%ation was
ro+ided &$ t,e !reditor "or t,at arti!u#ar %ont,9 An e-#anation aears
on t,e re+erse side o" t,e +er$ #ast a'e o" $our Trans
F
Union !redit reort e-#ainin' w,at ea!, nu%&er %eans9 T,e e-#anations
wi## &e under t,e ,eadin'6 <OP Current <anner o" Pa$%ent9
T,e "ina# &#o!1 o" in"or%ation to t,e "ar ri',t o" t,e Trans Union
reort indi!ates t,e a!!ount t$e and !urrent %et,od o" a$%ent =<OP>9
T$es o" a!!ounts in!#ude re+o#+in'2 oen2 insta##%ent2 %ort'a'e2 and so
on9 Current %et,od o" a$%ent re"#e!ts t,e ti%e#iness o" t,e a$%ents
$ou %a1e on an a!!ount9 <ost o" t,e a!!ounts on t,e sa%#e !redit reort
are re+o#+in' =R> and are aid wit,in )0 da$s =0*>9
T,e +er$ &otto% #ine o" in"or%ation "or ea!, a!!ount
resents %is!e##aneous additiona# re%ar1s a&out t,e a!!ount2 "or
e-a%#e6 t,at a!!ount in"or%ation is &ein' disuted9 T,ere are no
%is!e##aneous additiona# re%ar1s in t,e sa%#e !redit reort9
In(uiries
T,is in"or%ation "o##ows t,e !redit ,istor$ se!tion o" t,e Trans
Union reort9 Li1e t,e reorts o" t,e ot,er !redit reortin' a'en!ies2 t,e
in7uiries se!tion s,ows w,o ,as %ade an in7uir$ re'ardin' $our !redit reort
and t,e date o" ea!, in7uir$9 T,e desi'nation 8Consu% Dis!i8 in t,e sa%#e
reort indi!ates t,at t,e !onsu%er re7uested a !o$ o" ,is or ,er own reort9
Fo##owin' t,e in7uiries is a #ist o" t,e !o%anies to w,o% Trans
Union ro+ided t,e !onsu%er;s na%e and address2 so t,e !o%anies !ou#d
o""er t,e !onsu%er !redit insuran!e2 and t,e dates t,e in"or%ation was
ro+ided9 T,e sa%#e reort s,ows t,at Trans Union ro+ided su!,
in"or%ation si- ti%es "ro% DCDG to *CD.9
&ublic Record
T,e u&#i! re!ord se!tion o" t,e Trans Union reort resents t,e
usua# in"or%ation on an$ a#i!a&#e #iens2 &an1rut!ies2 or Hud'%ents9
T,e words End of Credit Report desi'nate t,e "ina# a'e o" t,e
Trans Union reort9 I%%ediate#$ "o##owin' t,ese words are t,e addresses
and ,one nu%&ers o" t,e !redit &ureaus a""i#iated wit, Trans Union t,at
'enerated t,e reort9 On t,is reort it is Sar%a Centra# Te-as in San
Antonio9 Conta!t t,e o""i!e #isted ,ere i" $ou ,a+e an$ 7uestions a&out t,e
in"or%ation in $our Trans Union Credit reort9
FIGURE 3.2 Sample Trans Union Credit Report
Note: This is a copy of an actual credit file. Identifying information (i.e., name,
address, Social Security number, date of birth, account numbers, etc.) has been
removed to protect consumer's identity
8
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FIGURE 3.2 Sample Trans Union Credit Report 1Contin2ed3
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16
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.3 R,DIT R,&ORTI%- O%.)%, %,T!OR0 )TI/ITY 'Y'T,1
PART ONE
SECTION T(O
+ow to 6ppl* for Your
'econd 'ocial 'ecurit* %umber
12
2RE0ACE
2ART ONE+ SECTION T3O
According to the Social Security Administration any individual who feels that
their current social security number is causing them to be 4"is$"!$)t$g" $)"5or
s&'.(t" to )g$ti! prso)$l or (o)o*i( pro'l*s or h$r"ships4 is entitled to
request a new social security number. These are very broad guidelines and below we
have listed some additional reasons for which you may be approved for a new social
security number. The information contained herein has been created and copyrighted
by Primary Source. e guarantee that the information contained in this manual is
!""# factual and that it$s produced but not fully disseminated by the Social
Security Administration. %our local social security administration branch manager
views each case individually and &udges each case on its own merit and how it fits
within the parameters of the guidelines for approving requests for 'n
d
social security
numbers.
Please note that the reasons for which you may be approved $r i) )o ,$y li*it" to
th %ollo,i)g6
NOTE6 2LEASE USE T7E 4RE8UEST 0OR SOCIAL
SECURITY STATEMENT4 0OUND ON T7E 0OLLO3ING 2AGE TO
C7EC9 I0 T7E SOCIAL SECURITY ADMINISTRATION 7AS MI:ED
TOGET7ER YOUR EARNING RECORDS 3IT7 SOMEONE ELSE#
Cr"it r(or" problems(abuse
Cr"it ($r" theft
;r
d
p$rty use to obtain economic gain.
I")tity th%t+ as well as personal information theft.
Th SSA < IRS have mi)ed together your earnings records with someone else.
U)$&thori=" *rgi)g of credit records with someone else.
I")ti($l name cases
>i(ti*s of harassment or abuse* e)ample +but in no way limited to, battered spouses or lovers.
Do*sti( !iol)( !i(ti*s#
St$l?i)gs
R$p
Thr$ts of bodily harm and(or death.
7$r$ss*)t by another party who is
tracing you through your number.
Rligio&s ob&ections or concerns.
Cri*i)$l record problems as a result of someone using your number.
B$)?r&pt(y resulting from fraud and(or unauthori-ed use of your number.
0i)$)(i$l distress that resulted from the misuse of your number and(or was the result
of unpaid financial obligations preceding a divorce.
0ollo,i)g $ "i!or(+ financial obligations not met through no fault of your own and
impacted you economically.
'&
!orm Approved
"#$ %o. &'&-&(
.equest for Social Security Statement
Pl ease check thi s box i f you a!t t o "et you# st at e$e!t i ! %&a!i sh i !stea' of
(!"l i sh.
Pl eas e &# i !t o# t y&e you# a!s e# s . )he! you ha*e co$&l ete' the fo#$+ fol ' i t a!' $ai l i t to us.
, I f you &# ef e# t o se!' you# # e-uest usi !" t he I!te#!et+ co!tact us at www.ssa.goy(
@(r item% ) anR D %-(w (n"I earnin3% =(*ereR PI 1(=ia" 1e=$ritI. D( ./0 i !cl u'e a"es f#o$
%t at e+ l ocal o# 1e'e#al 2o*e# !$e!t e$&l oy$e!t t hat a#e ./0 co*e#e' fo# %oci al %ecu#i ty o# that
a#e co*e#e' /.34 by Me'i ca#e.
6. %ho you# actual ea#!i !"s ,a"es a!'/o# !et sel f 5 e$&l oy$e!t i !co$e6 f o# l ast yea# a!' you#
esti $ate' ea#!i !"s fo# thi s yea#.
A. 3ast yea#7s actual ea#!i!"s8 &ollars %nly(
9. 9o you a!t us t o se!' t he st at e$e!t 8
0o you: (!te# you# !a$e a!' $ail i!" a''#ess.
0o s o$eo!e el s e , you# accou!t a!t + &e!sio! &la!+ etc.6: (!te# you# !a$e ith ;c/o; a!' the
!a$e a!' a''#ess of that &e#so! o# o#"a!i <ati o!.
o# %t#eet A''#ess ,I!cl u'e A&t. .o.+ P./. =ox+ >u#al >oute6
1. .a$e sho! o! you# %oci al %ecu#i ty ca#'8
2 2
%t#eet A''#ess
1 =. 0his yea#7s esti$ate' ea#!i!"s8 &ollars %nly(
%t#eet A''#ess If 1o#ei "! A''#ess+ e!te# Ci ty+ P#o*i !ce+ Post al Co'e6
1i#st .a$e Mi''le I!itial

2 2
?.%. Ci t y+ %t at e+ @i & co'e If 1o#ei "! A''#ess+ e!t e# .a$e of Cou!t #y
3ast .a$e /!ly
'.
A6 4ou# %oci al %ecu#i ty !u$be# as sho! o! you# ca#'8
A. 4ou# 'at e of bi # t h , Mo 5 9ay 5 4# . 6
3. /the# %oci al %ecu#i ty !u$be#s you ha*e use'8
B. 4ou# %ex8 Male 1e$ale
C. %ho the a"e at hich you &la! to sto& o#ki !"
&Show only one age(
6. =el o+ sho the a*e#a"e yea#l y a$ou!t ,!ot you# total futu#e l i feti $e ea#!i !"s6 that you t hi !k
you i l l ea#! bet ee! !o a!' he! you &l a! t o st o& o#ki !". I!cl u'e
&e#fo#$a!ce o# sche'ul e' &ay i !c#eases o# bo!uses+ but !ot cost5of5l i *i !" i !c#eases.
If you ex&ect t o ea#! si "!i fi ca!tl y $o#e o# l ess i ! the futu#e 'ue t o &#o$ot i o!s+ D ob cha!"es+
&a#t 5t i $e o#k+ o# a! abse!ce f#o$ the o#k f o# ce+ e!t e# t he a$ou!t t hat $os t cl os el y #efl ects
you# futu#e a*e#a"e yea#l y ea#!i !"s.
If you 'o!7 t ex&ect a!y si "!i fi ca!t cha!"es+ sho the sa$e a$ou!t you a#e ea#!i !" !o ,the
a$ou!t i ! 6=6.
1utu#e a*e#a"e yea#ly ea#!i!"s8 &ollars %nly(
2
)"C*A+
)*,,-*
A.%/*%*)
*-# *"%
bo!t T"e #ri$a%y %t
Social Security is allowed to collect the facts on this
form under section 205 of the Social Security Act. We
need them to quickly identify your record and prepare
the statement you asked us for. Givin us these facts is
voluntary. !owever" without them we may not #e a#le
to ive you a statement. $either the Social Security
Administration nor its contractor will use the
information for any other purpose.
R/&st %or So(i$l S(&rity
St$t*)t
%hank you for requestin this statement.
After you complete and return this form" we will &
within ' to ( weeks && send you)
a record of your earnins history and an
estimate of how much you have paid in
Social Security ta*es" and
estimates of #enefits you +and your
family,
We-re pleased to furnish you with this information and we hope you-ll find it useful in plannin your financial
future.
.ail completed form to)
Social Security Administration Wilkes /arre 0ata 1perations 2enter 3.1. /o* 400'
Wilkes /arre" 3A 154(4&400'
#aperwor& Red!%tion %t 'oti%e and Time It Ta&es (tatement
%he 3aperwork 6eduction Act of 1775 requires us to notify you that this information collection is in
accordance with the clearance requirements of section 8504 of the 3aperwork 6eduction Act of 1775. We may
not conduct or sponsor" and you are not required to respond to" a collection of information unless it displays a
valid 1./ control num#er. We estimate that it will take a#out 5 minutes to complete this form. %his
includes the time it will take to read the instructions" ather the necessary facts and fill out the form.
Social Security is more than 9ust a proram for retired people. :t helps people of all aes in many ways.
Whether you-re youn or old" male or female" sinle or married && Social Security can help you when you need it
most. :t can help support your family in the event of your death and pay you #enefits if you #ecome severely
disa#led.
:f you have questions a#out Social Security or this form" please call our toll&free num#er" )*+,,*--.*).)/.
%();.1" S<ct",t,
s01/(
)
%
--("0111111)
18
INTRODUCTION
,art ;ne, "ection Two of this booklet is designed to provide you with simple step
by step instructions for preparing a successful request for a second "ocial
"ecurity -umber. The following guidelines have been produced by ,rimary
"ource to assist individuals who feel they are deemed eligible to receive a new
"ocial "ecurity -umber. 3f your "ocial "ecurity -umber is causing you to be
financially disadvantaged, you may submit a request for a new "ocial "ecurity
-umber by following the guidelines provided.
THE <OST SI<PLE MUSTIFICATION FOR RENUESTING A SECOND SOCIAL
SECURITY NU<BER
The following reasons for requesting a second "ocial "ecurity -umber appear as
outlined by the "ocial "ecurity *dministration<
The most common .ustification is that the "ocial "ecurity *dministration or
the 3nternal 5evenue "ervice has mi!ed together earnings records from
more than one person, if this has happened to you and the other party
cannot be located, it will be necessary for you to be issued a new
number.
;ne of the easiest situations that the "ocial "ecurity *dministration accepts
.ustifying a new number is if your "ocial "ecurity -umber contains the
sequence === or 0>. The digits need to be consecutive according to the
"ocial "ecurity *dministration policy manual, but may be separated by
hyphens.
?!ample<
9>@A0>A19B=AThis is acceptable means for requesting a new number because the
numerical order of the one and three are consecutive.
9>@A20A>19BAThis is also acceptable means for requesting a new number even if
the one and three are separated by hyphens.
=01A2@A===BAThis is acceptable means for requesting a new number because the
numerical order of the si!es are consecutive.
=01A2=A==BBAThis is also acceptable means for requesting a new number even if
the si!es are separated by hyphens.
The "ocial "ecurity *dministration states that you don(t have to prove that your
religious ob.ection is sincere. ;ther commonly accepted complaints include that
someone is harassing you and is tracing you through your "ocial "ecurity
-umber, sequential numbers assigned to family members, or serious impact on
your credit history that you(ve tried to clear up without success. ou will find
helpful forms contained in the back of this booklet for disputing negative credit
information.
07
HO( TO APPLY FOR A SECOND SOCIAL SECURITY NU<BER DUE TO
ECONO<IC OR PERSONAL HARDSHIP
The following steps are simple, but effective. These guidelines have successfully
assisted many clients in their petition for a new "ocial "ecurity -umber.
1T70 1-Writin3 I($r reS$e%t f(r a 1e=(nR 1(=ia" 1e=$ritI N$mPer
Cegin by writing down the reasons you believe you are deserving of a 2
nd

"ocial "ecurity -umber.
?!plain how your current situation came about, causing you to resort to
believing that receiving a 2
nd
"ocial "ecurity -umber will alleviate your
unfavorable situation.
3nclude why this current situation is disadvantageous to you, or sub.ecting you
to negative economic or personal hardships.
3f you feel that this situation is affecting your emotion wellAbeing, causing a
loss of personal freedom or a threat to your personal safety, be sure to include
this in your petition.
Ce sure to include at what point in time this situation arose. The situation that
you based your request for a new "ocial "ecurity -umber should have
occurred within the last year, or it still must be affecting you today.
When possible, document your claims. 4or e!ample, include references to
denied requests for credit, denied requests for a home mortgage, credit report
disputes, court records, police reports, etc. 3nclude copies of these documents
with your request for a new "ocial "ecurity -umber.
$onclude your petition by emphasi'ing how a new "ocial "ecurity -umber will
alleviate the problems caused by your old "ocial "ecurity -umber.
DE>ELO2 YOUR CASE
37AT@
/AT /APP01023 /AT AS 2410 T4 %45 A12 6% /473
DE>ELO2 YOUR CASE
W0Y1
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DE>ELO2 YOUR CASE
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/A.2S/9P3 /4 /AS T/9S ;A5S02 %45 T4 <4S0 %45. P0.S41A< ?.00247 4. ?0A.
?4. %45 SA?0T%3 /4 /AS T/9S A??0;T02 %45. 074T941A< 0<< 6091:3
DE>ELO2 YOUR CASE
37EN@
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/A=0 /APP0102 ?5.T/0. 91 T/0 PAST 65T T/0 P.46<07 9TS0<? ;41T9150S 14 A12
9T$S ST9<< A??0;T91: %45 T42A%.
DE>ELO2 YOUR CASE
W0O1
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T/9S P0.S41 A1 5169AS02 T/9.2 PA.T% S5;/ AS A1 ATT4.10%* A;;451TA1T*
P4<9;0 4??9;0.* 0%09T10SS* 4. 9S T/0 91?4.7AT941 %45 S5679T 91 S5PP4.T 4?
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?.47 A ;.029T 65.0A5* P4<9;0 .0P4.TS* A 201902 APP<9;AT941 ?4. ;.029T 4. A
/470 74.T:A:0* A 29=4.;0 20;.00* A <AS59T* 6A1@.5P;% 24;5701TAT941 A12
S441.
1A
1T70 ' - 0r(5er"I @(rmattin3 8($r /eS$e%t
Your etition "or a se!ond So!ia# Se!urit$ Nu%&er s,ou#d &e t$ed in a u#etter
"or%at89 At t,e to #e"t !orner o" t,e etition2 #ist $our "u## na%e and $our So!ia#
Se!urit$ Nu%&er as it aears on $our resent So!ia# Se!urit$ Card2 a#on'
wit, $our !urrent %ai#in' address and te#e,one nu%&er9 At t,e to ri',t
!orner2 &e sure to in!#ude t,e date $our etition was su&%itted9 Be sure to
re"er to t,e sa%#e etition &e#ow9
0&ll N$*
So(i$l S(&rity N&*'r
C&rr)t A""rss
Tlpho) N&*'r
To ,ho* it (o)(r)s6
D$t
Si)(rly+
Yo&r Sig)$t&r
1T70 3 - C(nta=tin3 I($r "(=a" 1(=ia" 1e=$ritI !Rmini%trati(n (ffi=e
You need to !onta!t $our #o!a# So!ia# Se!urit$ Ad%inistration &ran!, to
o&tain t,eir address and te#e,one nu%&er9 You %a$ do t,is &$ !onta!tin'
t,e %ain o""i!e in Ba#ti%ore2 <ar$#and at6 =/*0> )G*?/G009 Or $ou !an !onta!t
$our #o!a# dire!tor$ assistan!e ser+i!e9
1T70 4- C(m5"ete I($r 11-5 f(rm
En!#osed wit,in t,is &oo1#et is a SS?4 "or%9 A#t,ou', $ou %a$ a#read$ ,a+e a
So!ia# Se!urit$ nu%&er at t,e resent ti%e2 it is ne!essar$ "or $ou to
!o%#ete t,is "or% to re!ei+e a new So!ia# Se!urit$ Nu%&er9
1T70 5 - 1im5"I mai" I($r reS$e%tA
<ai# $our re7uest to $our #o!a# So!ia# Se!urit$ Ad%inistration o""i!e9
Con'ratu#ationsO You ,a+e now su!!ess"u##$ su&%itted an a&so#ute#$ er"e!t
re7uest "or $our new So!ia# Se!urit$ Nu%&erO
'OI6/ ',)RITY 6D1I%I'TR6TIO%
6pplication for a 'ocial 'ecurit* ard
!orm ))-2 *nternet 34-'56 .estroy 7rior 8ditions 7age /
6ppl*ing for a 'ocial 'ecurit* ard is eas* 6%D it is
7R,,A
If *ou DO %OT follow these instructions2 we 6%%OT process *our
applicationA
'T,& < $omplete and sign the application with C:8? or C:*$K ink.
/o -;T use pencilD 4ollow instructions below.
'T,& 2 "ee ,age 2 to determine what evidence we need.
'T,& : "ubmit the application and evidence to any "ocial "ecurity office. 4ollow
instructions
below.
+O! TO O1&/,T, T+, 6&&/I6TIO%
Most items on the form are selfAe!planatory. Those that need e!planation are
discussed below. The numbers match the numbered items on the form. 3f you are
completing this form for someone else, please complete the items as they apply to
that person.
2. "how an address where you can receive the card 02 to 07 days from
now.
>. 3f you check EotherE for $3T3F?-"#3,, provide a document from the
4ederalG"tate or local agency e!plaining why you need a "ocial "ecurity
number and that you meet all the requirements for the benefit or
service e!cept for a number.
7. ou do not have to complete this item about raceGethnic background.
We use this information for statistical reports on how "ocial "ecurity
programs affect people. We do not reveal the identities of individuals.
@. "how the month, day, and full %7Adigit& year of birth, for e!ample, E011BE
for year of birth.
=. ou must enter the mother(s "ocial "ecurity number in item BC. if you
are applying for a number for a child under age 0B.
9. ou must enter the father(s "ocial "ecurity number in item 1C. if you
are applying for a number for a child under age 0B.
<:. 3f the date of birth you show in item = is different from the date of birth you
used on a prior application for a "ocial "ecurity number card, show the
date of birth you used on the prior application and submit evidence of age
to support the date of birth in item =.
<6. ou must sign the application if you are age 0B or older and are
physically and mentally capable. 3f you are under age 0B, you may also
sign the application if you are physically and mentally capable. 3f you
cannot sign your name, you should sign with an EHE mark and have two
people sign as witnesses in the space beside the mark. 3f you are
physically or mentally incapable, generally a parent, close relative, or
legal guardian may sign the application. $all us if you need clarification
about who can sign.
+O! TO ')"1IT T+, 6&&/I6TIO%
Mail the form and your evidence documents to the nearest "ocial "ecurity office. We
will return your documents to you. 3f you do not want to mail your original documents,
take them to the nearest "ocial "ecurity office with this application.
If *ou are age <; or older and ha$e ne$er been assigned a number before2 *ou
must appl* in person.
!orm ))-2 *nternet 34-'56 7age 4
EBIDENCE (E NEED
6)TIO%3 !e cannot accept photocopies of documents. 9ou must submit
original documents or copies certified by the custodian of the record. %otariBed
copies are not acceptable. *f your documents do not meet this re:uirement, we
cannot process your application. We will return your documents. *! 9"; ." %"T
WA%T T" #A*+ 9";- "-*<*%A+ ."C;#8%T), TA=8 T>8# T" A%9 )"C*A+
)8C;-*T9 "!!*C8.
*f you need an ORI-I%6/ 6RD 3you have %8,8- been assigned a )ocial
)ecurity number before6, you must show us proof of ?
6-,2
ID,%TITY2 and
).'. ITIC,%'+I& or /6!7)/ 6/I,% 'T6T)'
*f you need a D)&/I6T, 6RD 3no name change6, you must show us proof of
ID,%TITY.
I1&ORT6%T3 *f you were born outside the ;.)., you must also show us proof of
).'. ITIC,%'+I& or /6!7)/ 6/I,% 'T6T)'.
*f you need a ORR,T,D 6RD because of a name change, you must show us
proof of ID,%TITY.
To +6%-, YO)R %61, on our records, we need one or more documents
identifying you by your "+. %A#8 on our records and your %8W %A#8.
I1&ORT6%T3 *f you were born outside the ;.)., you must also show us proof of
).'. ITIC,%'+I& or /6!7)/ 6/I,% 'T6T)'.
6-,3 We prefer to see your birth certificate. >owever, we can accept other
documents such as a hospital record of your birth made before you were age 2 or a
religious record made before you were three months old. *f you were born outside
the ;.)., we can accept your passport. Call us for advice if you cannot obtain any of
these documents.
ID,%TITY3 We must see a document in the name you want shown on the card.
We can generally accept a current document that has enough information to
identify you 3e.g., signature, name, age, date of birth, parents1 names6. !e
6%%OT 6,&T a "IRT+ ,RTI7I6T,2 +O'&IT6/ "IRT+ R,ORD2 ''%
6RD2 ''% 6RD 'T)"2 OR ''6 R,ORD. )ome documents that we can accept
are?
.river1s license @ #arriage or divorce record @ #ilitary records
8mployer *. card @ Adoption record @ *nsurance policy
7assport @ >ealth *nsurance card 3not @ )chool
*. card
a #edicare card6
I1&ORT6%T3 If *ou are appl*ing for a card on behalf of someone else2 we
must see proof of identit* for both *ou and the person to whom the card
will be issued.
!orm ))-2 *nternet 34-'56 7age A
NA<E CHANGE6 *f your name is now different from the name shown on your
card, we need an identity document that identifies you by $"T> your old name
A%. your new name. 8Bamples include a marriage certificate, divorce decree, or
a court order that changes your name. "r we can accept two identity documents
Cone in your old name and one in your new name. 3)ee *.8%T*T9 for
eBamples of identity documents.6
U9S9 CITIPENSHIP6 We can accept most documents that show you were born in
the ;.). *f you are a ;.). citiDen born outside the ;.)., show us a ;.). consular
report of birth, a ;.). passport, a Certificate of CitiDenship, or a Certificate of
%aturaliDation.
ALIEN STATUS6 We need to see a current document issued to you by the ;.).
*mmigration and %aturaliDation )ervice 3*%)6, such as !orm /-22/, /-'(, *-
55$, or /-E. We CA%%"T accept a receipt showing you applied for the
document. *f you are not authoriDed to work in the ;.)., we can issue you a
)ocial )ecurity card if you are lawfully here and need the number for a valid
nonwork reason. 9our card will be marked to show you cannot work, and, if you
do, we will notify *%).
IF YOU HABE ANY NUESTIONS6 *f you have any :uestions about this form, or
about the documents you need to show us, please contact any )ocial )ecurity
office. A telephone call will help you make sure you have everything you need to
apply for a card.
THE PAPER(ORQCPRIBACY ACT AND YOUR
APPLICATION
The 7rivacy Act of /'E( re:uires us to give each person the following notice
when applying for a )ocial )ecurity number.
)ections 4&23c6 and E&4 of the )ocial )ecurity Act allow us to collect the facts
we ask for on this form.
We use the facts you provide on this form to assign you a )ocial )ecurity number
and to issue you a )ocial )ecurity card. 9ou do not have to give us these facts,
however, without them we cannot issue you a )ocial )ecurity number or a card.
Without a number, you may not be able to get a Fob and could lose )ocial
)ecurity benefits in the future.
The )ocial )ecurity number is also used by the *nternal -evenue )ervice for taB
administration purposes as an identifier in processing taB returns of persons who
have income which is reported to the *nternal -evenue )ervice and by persons
who are claimed as dependents on someone1s !ederal income taB return.
We may disclose information as necessary to administer )ocial )ecurity
programs, including to appropriate law enforcement agencies to investigate
alleged violations of )ocial )ecurity lawG to other government agencies for
administering entitlement, health, and welfare programs such as #edicaid,
#edicare, veterans benefits, military pension, and civil service annuities,
black lung,
housing, student loans, railroad retirement benefits, and food stampsG to the
*nternal -evenue )ervice for !ederal taB administrationG and to employers and
former employers to properly prepare wage reports. We may also disclose
information as re:uired by !ederal law, for eBample, to the .epartment of
Hustice, *mmigration and %aturaliDation )ervice, to identify and locate aliens in
the ;.).G to the )elective )ervice )ystem for draft registrationG and to the
.epartment of >ealth and
!orm ))-2 *nternet 34-'56 7age (
#uman "ervices for child support enforcement purposes. We may verify "ocial
"ecurity numbers for "tate motor vehicle agencies that use the number in issuing
drivers licenses, as authori'ed by the "ocial "ecurity *ct. 4inally, we may disclose
information to your $ongressional representative if they request information to
answer questions you ask him or her.
We may use the information you give us when we match records by computer.
Matching programs compare our records with those of other 4ederal, "tate, or local
government agencies to determine whether a person qualifies for benefits paid by
the 4ederal government. The law allows us to do this even if you do not agree to it.
?!planations about these and other reasons why information you provide us
may be used or given out are available in "ocial "ecurity offices. 3f you want to
learn more about this, contact any "ocial "ecurity office.
The &aperworD Reduction 6ct of <995 requires us to notify you that this information
collection is in accordance with the clearance requirements of section >@29 of the
,aperwork 5eduction *ct of 011@. We may not conduct or sponsor, and you are
not required to respond to, a collection of information unless it displays a valid
;MC control number.
TI1, IT T60,' TO O1&/,T, T+I' 7OR1
We estimate that it will take you about B.@ to 1 minutes to provide the information.
This includes the time it will take to read the instructions, gather the necessary
facts and provide the information. *ll requests for "ocial "ecurity cards and other
claimsArelated information should be sent to *our local 'ocial 'ecurit*
office2 whose address is listed under "ocial "ecurity *dministration in the 8.".
Iovernment section of your telephone directory. $omments or suggestions on
our ETime it TakesE estimate are welcome and should be addressed to< "ocial
"ecurity *dministration, *TT-< 5eports $learance ;fficer, 0A*A20 ;perations
Cuilding, Caltimore, M/ 202>@A2220. "?-/ ;-: $;MM?-T" ;- ;85 ET3M?
3T T*K?"E ?"T3M*T? T; T#3" *//5?"".
SOCIAL SECURITY AD<INISTRATION A#i!ation "or a So!ia# Se!urit$ Card
4orm *pproved ;MC -o. 21=2A22==
NA<E
T; C? "#;W- ;- $*5/
4irst 4ull Middle -ame :ast
!;++ %A#8 AT $*-T> *! "T>8- T>A% A$",8
4irst 4ull Middle -ame :ast
"T>8- %A#8) ;)8.
"treet *ddress, *pt. -o., ,; Co!, 5ural 5oute -o.
2
$ity "tate Fip $ode
<AILING ADDRESS
/o -ot *bbreviate
)
2 8.". $i ti 'en
CITIPENSHIP
%$heck ;ne&
:egal *lien :egal *lien ;ther
p *llowed To El Not *llowed 8 %"ee 3nstructions
Work To Work ;n ,age 0&
/
SEE
U Male
4emale
4
#ispanic
RACECETHNIC
DESCRIPTION
%$heck ;ne ;nly+Joluntary&
*sian *sianA*merican
Or
,acific 3slander
Clack
KK %-ot
#ispanic&
-orth
White
%-ot #ispanic&
,AA, *merican :K 3ndian or
*laskan
-ative
G
DATE OF
BIRTH
.
Month, /ay, ear
PLACE OF BIRTH
%/o -ot *bbreviate&
/ffice ?se /!ly
$ity "tate or 4oreign $ountry 4$3
A9 F
4irst
4ull Middle -ame :ast -ame *t #er Cirth
A> <OTHER;S <AIDEN NA<E
A9 <OTHER;S SOCIAL SECURITY NU<BER
%$omplete only if applying for a number for a child under age 0B.&
4irst 4ull Middle -ame :ast
A9 D
A> FATHER;S NA<E
A9RRRRRRRFATHER;S
SOCIAL
SECURITY
NU<BER RRRRRRR
%$omplete only if applying for a number for a child under age 0B.&
>as the applicant or anyone acting on hisIher behalf ever filed for or received
a )ocial )ecurity number card beforeJ
2 es %3f EyesE, answer questions 00A0>.& ?l -o %3f EnoE, go on to question 07.&
rA0 /on(t Know %3f Edon(t knowE,
3 A 0 go on t o quest i on 07 &
/ &
**
*2
*)
*/
8nter the )ocial )ecurity number previously assigned to the person listed in item /.
4irst Middle :ast
8nter the name shown on the most recent )ocial )ecurity card issued for the person
l i sted i n i tem /. -K
8nter any different date of birth if used on an
earlier application for a card. LLLLLLLLLLL
Month, /ay, ear
TOD6Y#'
D6T,
Month, /ay, ear
D6YTI1,
&+O%, %)1",R *rea $ode -umber
*4
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IMP>I%/.M(.0+ /> =/0H.
*.
YOUR RELATIONSHIP TO THE PERSON IN ITE< * IS6
%el f (l .at u# al o# ri 3e"al (l /the# ,%&eci fy6
A'o&ti*e Pa#e!t 2ua# 'i a! 7 E7
*G
YOUR SIGNATURE
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-,- /;$ -T3 $*- 3TJ
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