SS-5
Application For Social Security Card
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the SS-5
Request may not be processed if the form is incomplete or illegible.
SOCIAL SECURITY ADMINISTRATION Application for a Social Security Card
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 -
Office Use Only -
FCI
4
DATE OF BIRTH -
MM/DD/YYYY
5
CITIZENSHIP
( 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)
6
ETHNICITY
Are You Hispanic or Latino? (Your Response is Voluntary) -
Yes -
No
7
RACE
Select One or More (Your Response is Voluntary)
Native Hawaiian -
Alaska Native -
Asian -
American Indian -
Black/African American -
Other Pacific Islander -
White
8
SEX -
Male -
Female
9
A. PARENT/ MOTHER'S NAME AT HER BIRTH
First
Full Middle Name
Last
B. PARENT/ MOTHER'S SOCIAL SECURITY NUMBER (See instructions for 9 B on Page 3)
Unknown
And much more...
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