Form SSA-1535-U3 Application for Search of Census Records for Proof of Ag

ONLY SHOW INFORMATION FOR CENSUS YEARS TO BE SEARCHED

-­

CENSUS
DATE

CITY, TOWN, TOWNSHIP
(Precinct, beat, etc.)

NUMBER AND STREET
(Very important)

NAME OF PERSON WITH WHOM
LIVING (Head of householdl

COUNTY AND STATE

RELATIONSHIP

APRil 15, 12A.
1910
JAN.1,
1920

126.

APRIL 1,
1930

12C.

APRIL 1,
1940

12D.
--­

DO NOT
USE
THIS
SPACE

2. WAGE EARNER'S NAME

1. CLAIM NUMBER

-­

3. FIRST NAME

MIDDLE NAME

MAIDEN NAME (if any)

....

CASE NO,

PRESENT LAST NAME

NICKNAME

6. SEX

15. PLACE OF BIRTH (City, County, State)

4. DATE OF BIRTH Ilf unknown, estimate)

9, ETHNICITY

8. FULL MAIDEN NAME OF MOTHER {Stepmother, etc,)

7, FULL NAME OF FATHER (Stepfather, guardian, etc.)

_
_

12, RACE (SELECT ONE OR MORE)
AMERICAN INDIAN OR ALASKA
NATIVE
ASIAN
BLACK OR AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER
PACIFIC ISLANDER
WHITE

ONLY SHOW INFORMATION CONCERNING MARRIAGES
PRIOR TO DATE OF LAST CENSUS YEAR TO BE SEARCHED

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10, FULL NAME OF HUSBAND OR WIFE

10A. YR. MARRIED
(Approximate)

11. FULL NAME OF HUSBAND OR WIFE

11A. YR, MARRIED
(Approximate)

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HISPANIC OR LATINO
NOT HISPANIC OR LATINO

13. REMARKS

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I authorize the Bureau of the Census to send the record to the Social Security Administration to be used by that agency only for
purposes in connection with my entitlement to Social Security benefits. (ATTENTION is called to the possibility that the
information shown in the census record may not agree with that given in your application. The record must be copied exactly as it
appears.)
14. SIGNATURE OF APPLICANT (Do not print)

If signed by mark (X), two witnesses must sign
below:

....

15. ADDRESS (Number and Street. City, State, ZIP Code)

15A. SIGNATURE OF WITNESS

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15B. SIGNATURE OF WITNESS

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AUTHORIZATION OF PAYMENT FOR CENSUS SEARCH

DISTRICT OFFICE ADDRESS (Number and Street, City, State, ZIP Code)

....

Please furnish census information and bill SSA, pursuant to
agreement between Bureau of Census and SSA,
SIGNATURE !District manager or
authorized employee)

,-----­
16A. DATE

....

FORM SSA-1535-U3 (7-2004) EF (07-2004)
Prior Edition May Be Used Until Exhausted

CENSUS BUREAU

See Revised Privacy Act Statement
PRIVACY ACT/PAPERWORK REDUCTION ACT NOTICE: This request is authorized by 20
CFR 404.71 6 of the Social Security regulations. The information on this form will be
forwarded by the Social Security Administration to the Bureau of the Census for their use
in searching their records for establishing your age. While providing this identifying
information is voluntary, failure to provide information which could help establish your age
may prevent an accurate and timely decision on any claim filed or could result in the loss
of some benefits in insurance coverage. Any proof of age which the Bureau of the Census
may have, will become part of your claim file.
PAPERWORK REDUCTION ACT NOTICE:
This information collection meets the clearance requirements of 44 U.S.C. §3507, as
amended by Section 2 of the Paperwork Reduction Act Ql1995. 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 you about 12 minutes to read the
instructions, gather the facts, and answer the questions.
SEND OR BRING 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 21235-0001. Only comments relating to our
time estimate should be provided, not the completed form.

See Revised Paperwork Reduction Act
Statement

The following revised Privacy Act Statement will be inserted into the form
at its next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
20 CFR 404.716 of the Social Security regulations authorizes us to collect this
information. The information you provide will be forwarded by the Social Security
Administration to the Bureau of the Census for their use in searching their records for
establishing your age.
The information you furnish on this form is voluntary. However, failure to provide the
requested information could prevent an accurate or timely decision on your claim for
benefits.
We rarely use the information you supply for any purpose other than for determining
eligibility. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the
following:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and
Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, state and local level; and
4. To facilitate statistical research, audit or investigative activities necessary to
assure the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, state or local
government agencies. Information from these matching programs can be used to establish
or verify a person’s eligibility for Federally funded or administered benefit programs and
for repayment of payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our
programs and systems, is available on-line at www.socialsecurity.gov or at your local
Social Security office.

The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
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 12
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING 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 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed form.