SSA-706-F3

Letter To Custodian Of Birth Records

Download and Print the SSA-L706-F3

Request may not be processed if the form is incomplete or illegible.

Claim Number:   -   -     Date:

Custodian of Record: Please complete, sign and date part 5 of this form, include your seal if you have one, and return the form to requester/SSA.

PART 1 - TO BE COMPLETED BY REQUESTER

Sir/Madam:
I/the Social Security Administration (Circle One) need(s) to establish a date of birth for SSA purposes.

I request a certified copy/certification/verification (Circle One) of your record showing the date of birth based on:

The information below; or  The document attached.

Full Name at Birth:

Sex:

Date of Birth (Month, Day, Year):

Place of Birth (City, County, and State):

Mother's Maiden Name (First, Full Middle, Last):

Father's Name (First, Full Middle, Last):

I authorize the disclosure of the requested information to the Social Security Administration.

And much more...