Security Sponsor

Application for a Social Security Card

Applying for a Social Security Card is free!

USE THIS APPLICATION TO:

● Apply for an original Social Security card

● Apply for a replacement Social Security card

● Change or correct information on your Social Security number record IMPORTANT: You MUST provide a properly completed application and the required evidence before we can process your application. We can only accept original documents or documents certified by the custodian of the original record. Notarized copies or photocopies which have not been certified by the custodian of the record are not acceptable. We will return any documents submitted with your application. For assistance call us at 1-800-***-**** or visit our website at www.socialsecurity.gov.

Original Social Security Card

To apply for an original card, you must provide at least two documents to prove age, identity, and U.S. citizenship or current lawful, work-authorized immigration status. If you are not a U.S. citizen and do not have DHS work authorization, you must prove that you have a valid non-work reason for requesting a card. See page 2 for an explanation of acceptable documents.

NOTE: If you are age 12 or older and have never received a Social Security number, you must apply in person. Replacement Social Security Card

To apply for a replacement card, you must provide one document to prove your identity. If you were born outside the U.S., you must also provide documents to prove your U.S. citizenship or current, lawful, work-authorized status. See page 2 for an explanation of acceptable documents. Changing Information on Your Social Security Record To change the information on your Social Security number record (i.e., a name or citizenship change, or corrected date of birth) you must provide documents to prove your identity, support the requested change, and establish the reason for the change. For example, you may provide a birth certificate to show your correct date of birth. A document supporting a name change must be recent and identify you by both your old and new names. If the name change event occurred over two years ago or if the name change document does not have enough information to prove your identity, you must also provide documents to prove your identity in your prior name and/or in some cases your new legal name. If you were born outside the U.S. you must provide a document to prove your U.S. citizenship or current lawful, work-authorized status. See page 2 for an explanation of acceptable documents. LIMITS ON REPLACEMENT SOCIAL SECURITY CARDS

Public Law 108-458 limits the number of replacement Social Security cards you may receive to 3 per calendar year and 10 in a lifetime. Cards issued to reflect changes to your legal name or changes to a work authorization legend do not count toward these limits. We may also grant exceptions to these limits if you provide evidence from an official source to establish that a Social Security card is required. IF YOU HAVE ANY QUESTIONS

If you have any questions about this form or about the evidence documents you must provide, please visit our website at www.socialsecurity.gov for additional information as well as locations of our offices and Social Security Card Centers. You may also call Social Security at 1-800-***-****. You can also find your nearest office or Card Center in your local phone book.

SOCIAL SECURITY ADMINISTRATION

Form SS-5 (10-2021) UF

Use (11-2019) UF Until Stock Is Exhausted

Page 1 of 5

OMB No. 0960-0066

EVIDENCE DOCUMENTS

The following lists are examples of the types of documents you must provide with your application and are not all inclusive. Call us at 1-800-***-**** if you cannot provide these documents. IMPORTANT : If you are completing this application on behalf of someone else, you must provide evidence that shows your authority to sign the application as well as documents to prove your identity and the identity of the person for whom you are filing the application. We can only accept original documents or documents certified by the custodian of the original record. Notarized copies or photocopies which have not been certified by the custodian of the record are not acceptable.

Evidence of Age

In general, you must provide your birth certificate. In some situations, we may accept another document that shows your age. Some of the other documents we may accept are:

● U.S. hospital record of your birth (created at the time of birth)

● Religious record established before age five showing your age or date of birth

● Passport

● Final Adoption Decree (the adoption decree must show that the birth information was taken from the original birth certificate)

Evidence of Identity

You must provide current, unexpired evidence of identity in your legal name. Your legal name will be shown on the Social Security card. Generally, we prefer to see documents issued in the U.S. Documents you submit to establish identity must show your legal name AND provide biographical information (your date of birth, age, or parents' names) and/or physical information (photograph, or physical description - height, eye and hair color, etc.). If you send a photo identity document but do not appear in person, the document must show your biographical information (e.g., your date of birth, age, or parents' names). Generally, documents without an expiration date should have been issued within the past two years for adults and within the past four years for children. As proof of your identity, you must provide a:

● U.S. driver's license; or

● U.S. State-issued non-driver identity card; or

● U.S. passport

If you do not have one of the documents above or cannot get a replacement within 10 work days, we may accept other documents that show your legal name and biographical information, such as a U.S. military identity card, Certificate of Naturalization, employee identity card, certified copy of medical record (clinic, doctor or hospital), health insurance card, Medicaid card, or school identity card/record. For young children, we may accept medical records

(clinic, doctor, or hospital) maintained by the medical provider. We may also accept a final adoption decree, or a school identity card, or other school record maintained by the school. If you are not a U.S. citizen, we must see your current U.S. immigration document(s) and your foreign passport with biographical information or photograph.

WE CANNOT ACCEPT A BIRTH CERTIFICATE, HOSPITAL SOUVENIR BIRTH CERTIFICATE, SOCIAL SECURITY CARD STUB OR A SOCIAL SECURITY RECORD as evidence of identity. Evidence of U.S. Citizenship

In general, you must provide your U.S. birth certificate or U.S. Passport. Other documents you may provide are a Consular Report of Birth, Certificate of Citizenship, or Certificate of Naturalization. Evidence of Immigration Status

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 page 3, item 5 for more information. Form SS-5 (10-2021) UF Page 2 of 5

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 ” 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 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 7 to 14 days from now. 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, a legal guardian, parent, or close relative may generally 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. Call us if you have questions about who may sign your application.

HOW TO SUBMIT THIS APPLICATION

In most cases, you can take or mail this signed application with your documents to any Social Security office. Any documents you mail to us will be returned to you. Go to https://secure.ssa.gov/apps6z/FOLO/fo001.jsp to find the Social Security office or Social Security Card Center that serves your area. Form SS-5 (10-2021) UF Page 3 of 5

PROTECT YOUR SOCIAL SECURITY NUMBER AND CARD

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-***-**** (TTY 1-800-***-****). 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.

Form SS-5 (10-2021) UF Page 4 of 5

15

Office

Use Only

SOCIAL SECURITY ADMINISTRATION OMB No. 0960-0066

1

NAME

TO BE SHOWN ON CARD

First Full Middle Name Last

FULL NAME AT BIRTH

IF OTHER THAN ABOVE

First Full Middle Name Last

OTHER NAMES USED

2 Social Security number previously assigned to the person listed in item 1

3 PLACE OF

BIRTH

(Do Not Abbreviate) City State or Foreign Country FCI DATE

OF

BIRTH MM/DD/YYYY

5 CITIZENSHIP

ETHNICITY

Are You Hispanic or Latino?

(Your Response is Voluntary) 7

RACE

Select One or More

(Your Response

is Voluntary)

8 SEX

A. PARENT/ MOTHER'S

NAME AT HER BIRTH

First Full Middle Name Last

B. PARENT/ MOTHER'S SOCIAL SECURITY

NUMBER (See instructions for 9B on Page 3)

10

A. PARENT/ FATHER'S

NAME

First Full Middle Name Last

B. PARENT/ FATHER'S SOCIAL SECURITY

NUMBER (See instructions for 10B on Page 3)

11 Has the person listed in item 1 or anyone acting on his/her behalf ever filed for or received a Social Security number card before?

12 Name shown on the most recent Social

Security card issued for the person

listed in item 1

First Full Middle Name Last

13 Enter any different date of birth if used on an earlier application for a card MM/DD/YYYY

14 TODAY'S

DATE MM/DD/YYYY

DAYTIME PHONE

NUMBER Area Code Number

16 MAILING ADDRESS

Street Address, Apt. No., PO Box, Rural Route No.

City State/Foreign Country ZIP Code

17

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. YOUR SIGNATURE

18

YOUR RELATIONSHIP TO THE PERSON IN ITEM 1 IS:

DO NOT WRITE BELOW THIS LINE (FOR SSA USE ONLY)

NPN DOC NTI CAN ITV

PBC EVI EVA EVC PRA NWR DNR UNIT

EVIDENCE SUBMITTED SIGNATURE AND TITLE OF EMPLOYEE(S) REVIEWING EVIDENCE AND/OR CONDUCTING

INTERVIEW

DATE

DCL DATE

(Do Not Abbreviate)

4

(Check One)

U.S. Citizen

Legal Alien

Allowed To

Work

Legal Alien Not Allowed To

Work(See Instructions On

Page 3)

Other (See

Instructions On

Page 3)

Yes No

Native Hawaiian

Alaska Native

Asian

American Indian

Black/African

American

Other Pacific

Islander

White

Male Female

Unknown

Unknown

Yes (If "yes" answer questions 12-13) No Don't Know (If "don't know," skip to question 14.) Self Natural Or

Adoptive Parent

Legal

Guardian

Other

Specify

Form SS-5 (10-2021) UF

Use (11-2019) UF Until Stock Is Exhausted

Page 5 of 5

Application for a Social Security Card

6

9

Contact this candidate