Form SSA-L706-F3 Letter to Custodian of Birth Records

Form Approved
OMB No. 0960-0693

Social Security Administration

LETTER TO CUSTODIAN OF BIRTH RECORDS
Claim Number:
Date:
Custodian of Record: Please complete, sign and date part 5 of this form, include your seal if you have
one, and return the form to requester/SSA.
PART 1 - TO BE COMPLETED BY REQUESTER
Sir/Madam:
I/
the Social Security Administration (Check One) need(s) to establish a date of birth for SSA purposes. I
request a certified
copy/
certification/
verification (Check One) of your record showing the date of birth
based on:
The information below; or
The document attached.
Full Name at Birth:

Sex:

Date of Birth (Month, Day, Year):

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

Mother's Maiden Name (First, Full Middle, Last):

Father's Name (First, Full Middle, Last):

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

Print Full Name

Relationship to Above Person (e.g., Self, Authorized Applicant)

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.

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Form SSA-L706-F3 (09-2015) ef (09-2015)

LETTER TO CUSTODIAN OF BIRTH RECORDS
PART 3 - PAYMENT INFORMATION
Enclosed is $
in the form of:
• Personal Check
• Certified Check
• Money Order
• Credit Card (Type, Number, Expiration Date)
• No Fee Required
• Other
DO NOT SEND CASH.

PART 4 - COMPLETED BY SSA OFFICIAL TO INDICATE RETURN ADDRESS/TO VERIFY
REQUESTER'S IDENTITY
Signature

Social Security Office Name

Print Name and Title

Office Address

Office Telephone Number with Area Code

Extension
Verification of Requester's Identity (If Required)
I verified the requester's identity. The requester submitted the following as evidence of his/her identity:

PART 5 - TO BE COMPLETED BY RECORDS CUSTODIAN OR OFFICIAL
Choose option A, B, or C.
A.
Certified Birth Record Attached
B.

Certification/Verification of Birth Record
I verify the information on the document submitted.

I certify the information provided below.
Name As Shown on the Record

Date of Birth or Age

Type of Birth or Religious Record

Last

Next

If Age, As of Which Birthday?

Date of the Record

Place of Birth

Mother's Full Name

Nearest

Not Given

Father's Full Name
Remarks

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Form SSA-L706-F3 (09-2015) ef (09-2015)

LETTER TO CUSTODIAN OF BIRTH RECORDS
C.

Negative Certification/Verification

I searched for a
birth/
him/her for the year(s)
D.

religious (Check One) record for the person named in Part 1 and found no record for

Signature and Seal

Please sign and date, indicate your title, provide address, and affix seal if you have one or indicate that no seal
exists. Return to requester or SSA, as indicated on page 1.
Signature
Address
Title
Date
No Seal
Affix Seal

PRIVACY ACT STATEMENT
See Revised Privacy Act
Collection and Use of Personal Information Statement Attached
Section 205(a) of the Social Security Act, as amended, authorizes us to collect this information. We will use the
information you provide on this form to determine the age and/or citizenship of a person who is applying for Social
Security or Supplemental Security Income benefits.
Completion of this form is voluntary; however, if you do not complete this form, it may delay the determination of
that person's eligibility for benefits.
We rarely use this information you supply for any purpose other than for determining continuing 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 and improvement 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.
A complete list of routine uses for this information is available in our System of Records Notices entitled Claims
Folders Systems (60-0089) and the Master Beneficiary Record (60-0090). The notices, additional information
regarding this form, routine uses of information, and 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 only comments
relating to our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401
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Form SSA-L706-F3 (09-2015) ef (09-2015)