Who's preparing this application? Who's preparing this application? ApplicantParent of the ApplicantLegal Guardian of the ApplicantOther PLEASE NOTE: EFORMS DOES NOT FILE THIS FORM ON YOUR BEHALF. To file your application, print this form and mail or deliver it to your local Social Security office. Review "Evidence Documents" on the form to understand what supporting documentation you need to mail or bring. I understand. Click Next to proceed once you've read the above notice. Applicant's Name What is your relationship to the applicant? First Name: Middle Name: Last Name: Is your Birth Name DIFFERENT? Is your Birth Name DIFFERENT? YesNo "Birth name" refers to the name written on your birth certificate. Birth (First) Name: Birth (Middle) Name: Birth (Last) Name: Have you used ANY OTHER names in the past? Have you used ANY OTHER names in the past? YesNo For example, if you've used an alias or have legally changed your name. Enter any OTHER NAMES: (separate by commas) For example: "Jane Smith, Jane Doe, Jane Smith-Doe." Applicant's Mailing Address What is your STREET ADDRESS (only)? What is your CITY? What is your STATE? (or foreign country) Do not abbreviate. What is your ZIP CODE? Applicant's Phone Number What is your phone number? () Enter the first 3 digits of your phone number above. Enter the remaining digits of your phone number above. Birthplace and Date What is your DATE OF BIRTH? In what CITY were you born? In what STATE or FOREIGN COUNTRY were you born? Do not abbreviate. Citizenship What is your citizenship status? What is your citizenship status? U.S. CitizenLegal Alien Allowed to WorkLegal Alien Not Allowed to WorkOther Social Security Number Enter the FIRST THREE characters of your social security number: Enter the MIDDLE TWO characters of your social security number: Enter the LAST FOUR characters of your social security number: We'll only use this information to create your form.You may leave this blank if you prefer to handwrite this on your form. Gender What is your gender? What is your gender? MaleFemale The Social Security Administration's system requires a sex designation of either female or male. Ethnicity (Optional) This section is voluntary. Select all that apply or feel free to skip entirely. White Black/African American Asian American Indian Native Hawaiian Alaska Native Other Pacific Islander Are you Hispanic or Latino? Are you Hispanic or Latino? YesNo Mother's Information What was your mother's FIRST name at the time of her birth? What was your mother's MIDDLE name at the time of her birth? What was your mother's LAST name at the time of her birth? Do you know your mother's social security number? Do you know your mother's social security number? YesNo If this social security card application is for a minor, the social security numbers of both parents are required unless the parent was never assigned one. First three characters: Middle two characters: Last four characters: Father's Information What was your father's FIRST name at the time of his birth? What was your father's MIDDLE name at the time of his birth? What was your father's LAST name at the time of his birth? Do you know your father's social security number? Do you know your father's social security number? YesNo If this social security card application is for a minor, the social security numbers of both parents are required unless the parent was never assigned one. First three characters: Middle two characters: Final four characters: Application History Have you or anyone acting on your behalf behalf ever filed for or received a Social Security number card before? Have you or anyone acting on your behalf behalf ever filed for or received a Social Security number card before? YesNoUnsure What was the FIRST NAME shown on your most recent social security card? What was the MIDDLE NAME shown on your most recent social security card? What was the LAST NAME shown on your most recent social security card? If the name shown on your last social security card is the same as the name you entered in the first section, type it again here. Are you updating the date of birth shown on your social security record? Are you updating the date of birth shown on your social security record? YesNo Enter the date of birth you wish to update as listed on any prior applications or cards: Signature Do you want to sign the form now? Do you want to sign the form now? YesNo Please draw your signature: Clear Please draw your signature. What is today's date? Next Save Save and finish later
