Fillable Printable Social Security Card Application Form - Illinois
Fillable Printable Social Security Card Application Form - Illinois
Social Security Card Application Form - Illinois
SOCIAL SECURITY ADMINISTRATION
Application for a Social Security Card
Applying for a Social Security Card is easy AND it is FREE!
If you DO NOT follow these instructions, we CANNOT process your application!
STEP 1 Complete and sign the application with BLUE or BLACK ink.
Do NOT use pencil! Follow instructions below.
STEP 2 See Page 2 to determine what evidence we need.
STEP 3 Submit the application and evidence to any Social Security office. Follow instructions
below.
HOW TO COMPLETE THE APPLICATION
Most items on the form are self-explanatory. Those that need explanation 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.
2.Show an address where you can receive the card 10 to 14 days from now.
3.If you check “other” for CITIZENSHIP, provide a document from the Federal/State or local
agency explaining why you need a Social Security number and that you meet all the
requirements for the benefit or service except for a number.
5.You do not have to complete this item about race/ethnic background. We use this
information for statistical reports on how Social Security programs affect people. We do not
reveal the identities of individuals.
6.Show the month, day, and full (4-digit) year of birth, for example, “1998” for year of birth.
8.You must enter the mother’s Social Security number in item 8B. if you are applying for a
number for a child under age 18.
9.You must enter the father’s Social Security number in item 9B. if you are applying for a
number for a child under age 18.
13.If the date of birth you show in item 6 is different from the date of birth you used on a prior
application for a Social Security number card, show the date of birth you used on the prior
application and submit evidence of age to support the date of birth in item 6.
16.You must sign the application if you are age 18 or older and are physically and mentally
capable. If you are under age 18, you may also sign the application if you are physically
and mentally capable. 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. If you are physically or
mentally incapable, generally a parent, close relative, or legal guardian may sign the
application. Call us if you need clarification about who can sign.
HOW TO SUBMIT THE APPLICATION
Mail the form and your evidence documents to the nearest Social Security office. We will return your
documents to you. If you do not want to mail your original documents, take them to the nearest Social
Security office with this application.
If you are age 18 or older and have never been assigned a number before, you must apply in
person.
FormSS-5 Internet (2-98) Destroy Prior Editions Page 1
EVIDENCE WE NEED
CAUTION: We cannot accept photocopies of documents. You must submit original documents
or copies certified by the custodian of the record. Notarized copies are not acceptable. If your
documents do not meet this requirement, we cannot process your application. We will return your
documents. IF YOU DO NOT WANT TO MAIL YOUR ORIGINAL DOCUMENTS, TAKE THEM TO
ANY SOCIAL SECURITY OFFICE.
If you need an ORIGINAL CARD (you have NEVER been assigned a Social Security number before),
you must show us proof of :
AGE,
IDENTITY, and
U.S. CITIZENSHIP or LAWFUL ALIEN STATUS
If you need a DUPLICATE CARD (no name change), you must show us proof of IDENTITY.
IMPORTANT: If you were born outside the U.S., you must also show us proof of
U.S. CITIZENSHIP or LAWFUL ALIEN STATUS.
If you need a CORRECTED CARD because of a name change, you must show us proof of IDENTITY.
To CHANGE YOUR NAME on our records, we need one or more documents identifying you by your
OLD NAME on our records and your NEW NAME.
IMPORTANT: If you were born outside the U.S., you must also show us proof of
U.S. CITIZENSHIP or LAWFUL ALIEN STATUS.
AGE: We prefer to see your birth certificate. However, we can accept other documents such as a
hospital record of your birth made before you were age 5 or a religious record made before you were
three months old. If you were born outside the U.S., we can accept your passport. Call us for advice if
you cannot obtain any of these documents.
IDENTITY: We must see a document in the name you want shown on the card. We can generally
accept a current document that has enough information to identify you (e.g., signature, name, age,
date of birth, parents’ names). We CANNOT ACCEPT a BIRTH CERTIFICATE, HOSPITAL BIRTH
RECORD, SSN CARD, SSN CARD STUB, OR SSA RECORD. Some documents that we can accept
are:
● Driver’s license ● Marriage or divorce record ● Military records
● Employer ID card ● Adoption record ● Insurance policy
● Passport ● Health Insurance card (not ● School ID card
a Medicare card)
IMPORTANT: If you are applying for a card on behalf of someone else, we must see proof of
identity for both you and the person to whom the card will be issued.
FormSS-5 Internet (2-98) Page 2
NAME CHANGE: If your name is now different from the name shown on your card, we need an
identity document that identifies you by BOTH your old name AND your new name. Examples
include a marriage certificate, divorce decree, or a court order that changes your name. Or we can
accept two identity documents—one in your old name and one in your new name. (See IDENTITY
for examples of identity documents.)
U.S. CITIZENSHIP: We can accept most documents that show you were born in the U.S. If you are
a U.S. citizen born outside the U.S., show us a U.S. consular report of birth, a U.S. passport, a
Certificate of Citizenship, or a Certificate of Naturalization.
ALIEN STATUS: We need to see a current document issued to you by the U.S. Immigration and
Naturalization Service (INS), such as Form I-551, I-94, I-688B, or I-766. 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 if you are lawfully here and need the number for a valid nonwork
reason. Your card will be marked to show you cannot work, and, if you do, we will notify INS.
IF YOU HAVE ANY QUESTIONS: If you have any questions about this form, or about the
documents you need to show us, please contact any Social Security office. A telephone call will help
you make sure you have everything you need to apply for a card.
THE PAPERWORK/PRIVACY ACT AND YOUR APPLICATION
The Privacy Act of 1974 requires us to give each person the following notice when applying for a
Social Security number.
Sections 205(c) and 702 of the Social Security Act allow us to collect the facts we ask for on this
form.
We use the facts you provide on this form to assign you a Social Security number and to issue you a
Social Security card. You do not have to give us these facts, however, without them we cannot issue
you a Social Security number or a card. Without a number, you may not be able to get a job and
could lose Social Security benefits in the future.
The Social Security number is also used by the Internal Revenue Service for tax administration
purposes as an identifier in processing tax returns of persons who have income which is reported to
the Internal Revenue Service and by persons who are claimed as dependents on someone’s
Federal income tax return.
We may disclose information as necessary to administer Social Security programs, including to
appropriate law enforcement agencies to investigate alleged violations of Social Security law; to
other government agencies for administering entitlement, health, and welfare programs such as
Medicaid, Medicare, veterans benefits, military pension, and civil service annuities, black lung,
housing, student loans, railroad retirement benefits, and food stamps; to the Internal Revenue
Service for Federal tax administration; and to employers and former employers to properly prepare
wage reports. We may also disclose information as required by Federal law, for example, to the
Department of Justice, Immigration and Naturalization Service, to identify and locate aliens in the
U.S.; to the Selective Service System for draft registration; and to the Department of Health and
FormSS-5 Internet (2-98) Page 3
FormSS-5 Internet (2-98) Page 4
Human Services for child support enforcement purposes. We may verify Social Security numbers for
State motor vehicle agencies that use the number in issuing drivers licenses, as authorized by the
Social Security Act. Finally, we may disclose information to your Congressional representative if they
request information to answer questions you ask him or her.
We may use the information you give us when we match records by computer. Matching programs
compare our records with those of other Federal, State, or local government agencies to determine
whether a person qualifies for benefits paid by the Federal government. The law allows us to do this
even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given
out are available in Social Security offices. If you want to learn more about this, contact any Social
Security office.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in
accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of
1995. We may not conduct or sponsor, and you are not required to respond to, a collection of
information unless it displays a valid OMB control number.
TIME IT TAKES TO COMPLETE THIS FORM
We estimate that it will take you about 8.5 to 9 minutes to provide the information. This includes the
time it will take to read the instructions, gather the necessary facts and provide the information. All
requests for Social Security cards and other claims-related information should be sent to your
local Social Security office, whose address is listed under Social Security Administration in the
U.S. Government section of your telephone directory. Comments or suggestions on our “Time it
Takes” estimate are welcome and should be addressed to: Social Security Administration, ATTN:
Reports Clearance Officer, 1-A-21 Operations Building, Baltimore, MD 21235-0001. SEND ONLY
COMMENTS ON OUR “TIME IT TAKES” ESTIMATE TO THIS ADDRESS.
17
15
DATE
OF
BIRTH Month, Day, Year City State or Foreign Country
A.MOTHER’S MAIDEN
NAME
B. MOTHER’S SOCIAL SECURITY
NUMBER
(Complete only if applying for a number for a child under age 18.)
YOUR SIGNATURE YOUR RELATIONSHIP TO THE PERSON IN ITEM 1 IS:
Has the applicant or anyone acting on his/her behalf ever filed for or received a Social Security
number card before?
Enter the Social Security number previously
assigned to the person listed in item 1.
Enter the name shown on the most
recent Social Security card issued for
the person listed in item 1.
Enter any different date of birth if used on an
earlier application for a card.
Month, Day, Year
TODAY’S DAYTIME ( )
DATE PHONE NUMBER
A.FATHER’S NAME
B. FATHER’S SOCIAL SECURITY
NUMBER
(Complete only if applying for a number for a child under age 18.)
NAME
TO BE SHOWN ON CARD
FULL NAME AT BIRTH
IF OTHER THAN ABOVE
OTHER NAMES USED
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) REVIEW-
ING EVIDENCE AND/OR CONDUCTING INTERVIEW
DATE
DATE
Yes (If “yes”, answer questions 11-13.) No (If “no”, go on to question 14.)
SOCIAL SECURITY ADMINISTRATION Application for a Social Security Card
Form Approved
OMB No. 0960-0066
First Full Middle Name Last
MAILING
ADDRESS
Do Not Abbreviate
1
2
CITIZENSHIP
(Check One)
SEX
RACE/ETHNIC
DESCRIPTION
(Check One Only—Voluntary)
Street Address, Apt. No., PO Box, Rural Route No.
City State Zip Code
Legal Alien
Allowed To
Work
Legal Alien
Not Allowed
To Work
Other
(See Instructions
On Page 1)
North
American
Indian or
Alaskan
Native
3
PLACE OF
BIRTH
4
5
6
FCI
Office
Use
Only
First Full Middle Name Last Name At Her Birth
Month, Day, Year Area Code Number
DELIBERATELY FURNISHING (OR CAUSING TO BE FURNISHED) FALSE INFORMATION ON THIS APPLICATION IS A CRIME PUNISHABLE BY FINE OR IMPRISONMENT, OR BOTH.
8
9
10
14
16
Self
Other (Specify)Natural or
Adoptive Parent
Legal
Guardian
Don’t Know (If “don’t know”,
go on to question 14.)
7
Form SS-5 Internet (2-98) Destroy Prior Editions Page 5
(Do Not Abbreviate)
▲
➤
➤
➤
➤
➤
➤
➤
➤
➤
➤
➤
U.S. Citizen
Hispanic
Asian
Asian-American
or
Pacific Islander
White
(Not
Hispanic)
Male
Female
11
13
First Middle Last
➤
➤
➤
DCL
First Full Middle Name Last
Black
(Not
Hispanic)
First Full Middle Name Last
12
WHEN YOU APPLY FOR A CHILD'S
SOCIAL SECURITY NUMBER
You may need this additional information to complete items 8.B. and 9.B.
on Form SS-5, Application for a Social Security Card.
When you apply for a Social Security number for a child under age 18, you need
to provide each parent's Social Security number unless the-
• parent does not have a Social Security number;
• parent's Social Security number is not known.
If you can't provide the parent's Social Security number for one of the reasons
listed above, we'll still be able to assign the child a Social Security number.
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
CUANDO USTED SOLICITA UN NÚMERO
DE SEGURO SOCIAL PARA UN NIÑO
Usted podría necesitar esta información adicional para completar los
artículos 8.B. y 9.B. en el formulario SS-5, Solicitud para una tarjeta de
Seguro Social.
Cuando usted solicita un número de Seguro Social para un niño menor de 18
años, necesita proveer los números de Seguro Social de cada padre a menos
que-
• los padres no tengan números de Seguro Social;
• los números de Seguro Social de los padres sean desconocidos.
Si usted no puede proveer los números de Seguro Social de los padres por una
de las razones mencionadas arriba, todavía podremos asignar un número de
Seguro Social al niño(a).
Form SS-5-SUP (05-2000)
