Form SSA-704 Certification of Contents of Document(s) or Record(s)

FORM APPROVED
OMB No. 0960-0689

TOE 420

CERTIFICATION OF CONTENTS OF DOCUMENT(S) OR RECORD(S)

SOCIAL SECURITY ADMINISTRATION

SOCIAL SECURITY NUMBER

NAME OF NUMBER HOLDER

EXTRACT TRANSLATION OF (Specify)
Language Document

Every item in a block must be filled out with EXACT EXCERPTS from the document certified or the item must be marked "NS" or "Not shown." If the date on which an entry was made in a family record
is "not shown," indicate under "Remarks" any allegation as to when the document or record was established. Include any other pertinent information shown on the document under "Remarks." Cross out
all unused blocks, (e.g., if a certification is made only in block "A1," cross out "A2," " B," "C," "D," and "E.")

A. AGE, RELATIONSHIP OR CITIZENSHIP OF:
1. NAME OF PERSON AS SHOWN ON EVIDENCE

SEX

DATE OF BIRTH

MALE

PLACE OF BIRTH

FEMALE
NOT SHOWN
AGE

NOT
SHOWN

BIRTHDAY AGE SHOWN

LAST

NEXT

NAME OF FATHER

NOT GIVEN

DATE RECORDED (if religious record, show date of
ceremony)
NOT SHOWN

NEAREST
NOT SHOWN

NATURE OF EVIDENCE

AGE

NAME OF MOTHER

NOT SHOWN

AGE

CUSTODY OF DOCUMENT
APPLICANT
RECORD CUSTODIAN
OTHER (Relationship to Applicant)
DOCUMENT NO.
DATE DOCUMENT ISSUED (If certifying from a
PUBLIC
CUSTODIAN Bible, give date of publication or last copyright, and
complete part E)

NAME AND ADDRESS OF ISSUING AGENCY IF NOT A PUBLIC RECORD
(include ZIP Code)

2. NAME OF PERSON AS SHOWN ON EVIDENCE

SEX

DATE OF BIRTH

MALE

PLACE OF BIRTH

FEMALE
NOT SHOWN
AGE

NOT
SHOWN

BIRTHDAY AGE SHOWN

LAST

NEXT

NAME OF FATHER

NOT GIVEN

DATE RECORDED (if religious record, show date of
ceremony)
NOT SHOWN

NEAREST
NOT SHOWN

NATURE OF EVIDENCE

AGE

NAME OF MOTHER

NOT SHOWN

AGE

CUSTODY OF DOCUMENT
APPLICANT
RECORD CUSTODIAN
OTHER (Relationship to Applicant)
DOCUMENT NO.
DATE DOCUMENT ISSUED (If certifying from a
PUBLIC
CUSTODIAN Bible, give date of publication or last copyright, and
complete part E)

NAME AND ADDRESS OF ISSUING AGENCY IF NOT A PUBLIC RECORD
(include ZIP Code)

B. MARRIAGE OF:
NAME OF HUSBAND AS SHOWN ON EVIDENCE

NAME OF WIFE AS SHOWN ON EVIDENCE

PREVIOUS MARRIAGES
(0, 1, 2, etc.)
NOT
SHOWN

DATE OF BIRTH

PREVIOUS MARRIAGES
(0, 1, 2, etc.)
NOT
SHOWN

DATE OF BIRTH

AGE

AGE

BIRTHDAY AGE SHOWN
LAST

NEAREST

NEXT

NOT GIVEN

BIRTHDAY AGE SHOWN
LAST

NEAREST

NEXT

NOT GIVEN

MARRIAGE CERTIFICATE PLACE OF MARRIAGE
BIBLE (complete part E)

NATURE OF EVIDENCE

CUSTODY OF DOCUMENT

DATE OF MARRIAGE
RECORD
CUSTODIAN

APPLICANT

OTHER (Relationship
to Applicant)

NAME AND ADDRESS OF ISSUING AGENCY IF NOT A PUBLIC RECORD (include ZIP Code)

DOCUMENT NO.
PUBLIC
CUSTODIAN

C. DEATH OF:
NAME OF DECEASED AS SHOWN ON EVIDENCE

CUSTODY OF DOCUMENT
RECORD
CUSTODIAN
APPLICANT

DATE OF DEATH

NATURE OF EVIDENCE

PLACE OF DEATH

DEATH

OTHER (Relationship
to Applicant)

NAME AND ADDRESS OF ISSUING AGENCY IF NOT A PUBLIC RECORD ( include ZIP Code)

FORM

CAUSE OF DEATH

SSA-704-F3 (02-2013) EF (02-2013)

DOCUMENT NO.
PUBLIC
CUSTODIAN

(OVER)

D. SERVICE IN U.S. ARMED FORCES OF:
NAME OF PERSON AS SHOWN ON EVIDENCE

RANK

DATE OF BIRTH OR AGE

BRANCH ( Army, Navy, etc.)

SERIAL NO.

DATE BIRTH OR AGE RECORDED

NATURE OF EVIDENCE
ORIGINAL DISCHARGE

DATE ENLISTED OR INDUCTED

MEANS OF ENTRY INTO
SERVICE

DATE ENTERED ACTIVE DUTY

INDUCTED

DATE DISCHARGED OR RELEASED FROM ACTIVE DUTY

CALLED FROM INACTIVE DUTY

CHARACTER OF DISCHARGE:

ENLISTED

RE-ENLISTED

COMMISSIONED

REASON AND AUTHORITY FOR SEPARATION

NOT SHOWN

HONORABLE
OTHER (Describe)
PERSON SUBMITTING DOCUMENT, RELATIONSHIP TO APPLICANT, AND ADDRESS (include ZIP Code)

APPLICANT

CUSTODIAN DATE DOCUMENT ISSUED

NAME AND ADDRESS OF ISSUING AGENCY IF NOT A PUBLIC RECORD (include ZIP Code)

DOCUMENT NO.

E. EVALUATION OF FAMILY BIBLE OR SIMILAR FAMILY RECORD:
Claimant's allegation as to person who made the entry:
1. NAME

3. RELATIONSHIP TO CLAIMANT

2. ADDRESS (include ZIP Code)

4. DATE ENTRY MADE

Examination of record.
1. Does entire entry appear to have been made by the same person at the same time? Yes

No (Explain in Remarks)

2. Is record made in:
Ink
Pencil
Ballpoint Pen
3. Describe the condition of the paper (yellow, brittle, etc.), and the condition of the book:

Other

4. Is entry faded?
Yes
No
5. Does entry appear to be:
Old
Recent
6. Date Bible printed or published.
7. If photocopy cannot be submitted, answer the following:
a. Are entries arranged chronologically?
Yes
No (Explain in Remarks)
b. Name and date as shown in the entry immediately before and immediately after the entry for the claimant:
Entry before
8. a. Who has had custody of the record?

Entry after
c. When was the entry made?

b. Who made the entry?

F. REMARKS:

d. How does the claimant know this?

NOTE: - Do not use this form to abstract from any court order (e.g., divorce, annulment and adoption decrees, etc.) or to certify the contents
of any foreign (non-English) language document unless you are an authorized SSA translator.

G. AUTHENTICATION OF DOCUMENT(S) OR RECORD(S) DESCRIBED ABOVE.
CERTIFICATION: - I have personally examined the documents and records above and CERTIFY their contents in connection with an application for benefits under Title II,
Title XVI, and/or Title XVIII of the Social Security Act, as amended. Unless otherwise stated, all the entries herein are exact excerpts from such documents or records. The
entries are free from erasures, interlineation, or other alterations and the general appearance of the documents or records satisfactorily establish their authenticity. The
entries (in the case of original records) appear to have been made at the time the record was purportedly established, and there is no reason to doubt the validity of the
records or entries, unless otherwise stated and explained under "Remarks."

SIGNATURE

OFFICIAL TITLE
CLAIMS
REPRESENTATIVE
FIELD
REPRESENTATIVE

FORM SSA-704-F3 (02-2013) EF (02-2013)

DATE

SERVICE
REPRESENTATIVE

SENIOR CLAIMS
SPECIALIST

QUALITY ASSURANCE
SPECIALIST

DATA REVIEW
TECHNICIAN

CLAIMS DEVELOPMENT
CLERK

STATE RECORD
CUSTODIAN

OTHER
(Specify)

See Revised Privacy Act Statement Attached
Privacy Act Statement
(Certification of Contents of Document (s) or Record(s))
Sections 205(a), 163a(e), (1)(A) and (B), and 1631(f), of the Social Security Act, as amended, and
Title 20 CFR 404.707 authorizes us to collect this information. The information you provide will be
used to make a decision on the claimant’s application for benefits. Your response is voluntary.
However, failure to provide all or part of the requested information could prevent an accurate and
timely decision on the claimant’s applications.
We rarely use this information provided on this form for any other purpose other than for the
reasons explained above. 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, General Services Administration,
National Archives Records Administration 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 this information you provided 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 and administered benefit programs and for repayment of payments or
delinquent debts under these programs.
A complete list of routine uses for this information is available in System of Records
Notice 60-0089 and 60-0050. The notice, additional information regarding this form, and
information regarding our programs and systems, are available on-line at www.socialsecurity.gov or
at your local 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 OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also 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.
FORM SSA-704-F3 (02-2013) EF (02-2013)

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
PRIVACY ACT STATEMENT
Collection and Use of Personal Information
Sections 205(a), 806(a)-(b), 1631(e)(1)(A)-(B), and 1631(f) of the Social Security Act, as
amended, authorize us to collect this information. We will use the information you provide to
make a determination of eligibility for Social Security benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from making an accurate and timely decision on any claim filed.
We rarely use the information you supply for any purpose other than to make a determination
regarding benefits eligibility. However, we may use the information for the administration of
our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census
and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in
our Privacy Act System of Records Notices 60-0050, entitled Completed Determination Record-Continuing Disability Determinations, 60-0089, entitled Claims Folders Systems, and 60-0103,
entitled Supplemental Security Income Record and Special Veterans Benefits. Additional
information about these and other system of records notices and our programs is available
from our Internet website at www.socialsecurity.gov or at your local Social Security office.
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
incorrect payments or delinquent debts under these programs.