• - The gender field is required.
  • - The first name field is required.
  • - The last name field is required.
  • - The country birth field is required.
  • - The city birth field is required.
  • - The dob year field is required.
  • - The dob month field is required.
  • - The dob day field is required.
  • - The us citizen field is required.
  • - The mother first name field is required.
  • - The mother last name field is required.
  • - The father first name field is required.
  • - The father last name field is required.
  • - The address field is required.
  • - The city field is required.
  • - The zip code field is required.
  • - The agreement field is required.
  • - The email field is required.
  • - The phone number field is required.
  • - The email confirmation does not match.
  • - The Social Security number fields are required.
  • - The Birth Firstname and Lastname fields are required.
  • - The Other Firstname and Lastname fields are required.
  • - The Recent Firstname and Lastname fields are required.
  • - The Signature is required.
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Applicant's Basic Information
Gender
Did you have a different name at birth?
Are you using other names?
Does the name on your most recent Social Security Card match your name above?
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FDF
Social Security Form SS5
15 Office Use Only OMB No. 0960-0066 SOCIAL SECURITY ADMINISTRATION 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 Page 5 of 5 Application for a Social Security Card 6 9
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