Form SSA-L106 Letter to Custodian of Birth Records

SOCIAL SECURITY ADMINISTRATION OMB No. 0960-0693 _________

LETTER TO CUSTODIAN OF SCHOOL RECORDS

Claim Number _______________________

Date _________________________________

PART 1 – TO BE COMPLETED BY REQUESTER

___________________________________________

Name of Record Custodian

_______________________________________________________

Address of Record Custodian

______________________________________________________

Sir/Madam:

I need to establish my date of birth to become entitled to Social Security benefits. I am requesting verification of my age according to records that may be available at your school. I am providing the following information to help in searching your records.

Name as Registered in School Nickname

__________________________________________________ __________________________

Date of Birth (Month, Day, Year) ______________________________________________

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

Name(s) of Parent(s) or Guardian(s) (First, Full Middle, Last) ____________________________________

Schools Attended (In same city or school district)

(1) Name of School (If unable to remember, give location) Grade(s) Attended Date(s) Attended

____________________________________________ _______________ _____________

Residence at Time of Attendance

_____________________________________________________________________________________

Remarks

_____________________________________________________________________________________

(2) Name of School (If unable to remember, give location) Grade(s) Attended Date(s) Attended

____________________________________________ _______________ _____________

Residence at Time of Attendance

______________________________________________________________________________________

Remarks

____________________________________________________________________________________

______________________________________________________________________________________

Form SSA-L106-F3 (3-2005) Recycle Prior Editions Page 1

LETTER TO CUSTODIAN OF SCHOOL RECORDS

(3) Name of School (If unable to remember, give location) Grade(s) Attended Date(s) Attended

____________________________________________ _______________ _____________

Residence at Time of Attendance

____________________________________________________________________________________

Remarks

_____________________________________________________________________________________

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

___________________________ _________________________________

Signature Address

___________________________________ ___________________________________________

Print Full Name

___________________________ _________________________________

Phone Number with Area Code

PART 2 – NOTARIZATION OF REQUESTER’S SIGNATURE (If Required)

Notary Public should use the space below for notarization and placement of seal.

PART 3 – PAYMENT INFORMATION

Enclosed is $____________________in the form of:

• Personal Check

• Certified Check

• Money Order

• No Fee Required

• Other

DO NOT SEND CASH.

______________________________________________________________________________________

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LETTER TO CUSTODIAN OF SCHOOL RECORDS

Part 4 - CERTIFICATION BY CUSTODIAN OF SCHOOL RECORDS

• ____ The record is unavailable.

• ____ I certify the information below based on school records in my custody.

• Name of School _________________________________________

• Address of School_________________________________________

• Name as Shown on School Record ______________________________________

• Name(s) of Parent(s) or Guardian(s) ______________________________________

• Age or Date of Birth as Shown on School Records _____________________________

• Date of School Record (Month, Day, Year) _______________________________________________

• Place of Birth ________________________________________________________

• Remarks ____________________________________________________________

__________________________________________________________________________________

Signature and Title of Custodian of School Records

_____________________________________________________________________________________________________

Name of School or Agency Having Custody of Record

______________________________________________________________________________________________________

Address (Street, City, State, Zip Code)

___________________________________

Date

PRIVACY ACT/PAPERWORK REDUCTION ACT NOTICE

The Privacy Act requires us to notify you that we are authorized to collect this information by section 205(a) of the Social Security Act. You do not have to provide the information requested. The data you provide, however, will allow the Social Security Administration to determine the age and/or citizenship of a person who is applying for Social Security or Supplemental Security Income benefits. If you do not complete this form, that person may not be entitled to benefits. We do not disclose the information you provide to any person or other government agency.

We may also 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. Many agencies may use matching programs to find or prove that 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 give 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.

Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C, § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 10 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U.S. government agencies in your telephone directory or you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

______________________________________________________________________________________

Form SSA-L106 (3-2005) Recycle Prior Editions Page 3