Request for Numident Print out Record
To: Social Security Adm inistration OEO DERO ( FOI A Wor k gr oup) 300 N. Green Street
P.0. Box 33022
Balt im ore, MD 21290- 3022
To process your request for a copy of your Num ident printout, we need you to provide the following in form ation:
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_______________________________ |
______________________ |
__________________ |
(Narne) |
(Social Security Num ber) |
(Date of Birth) |
I f you do not know your Social Security number, please provide t he following inform at ion:
NAME:
PLACE OF BIRTH:
SEX:
DATE OF BIRTH:
MOTHER’S MAIDEN NAME:
FATHER’S NAME:
I n all cases, also provide t he following:
Mailing Address: |
Daytime Phone Number: |
______________________________________ |
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______________________________________ |
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Iam the nonresident hum an being and not statutory “ individual” to whom the false record pertains (or a person who is authorized to sign this letter on behalf of that party) . I understand that any false representation to knowingly and willfully obtain inform ation from Social Security records is punishable by a fine of not m ore than $5,000 or one year in prison.
Sincerely,
_______________________________________ |
__________________________ |
Signature |
Dat e |
Note: There is a fee for obtaining this printout. If you know the SSN, the charge if $16.00; if the SSN is not known, the charge is $18.00. The applicable fee must accompany this request. You may pay by check, money order, or MasterCard, Visa, Discover, American Express, or Diner's Club credit card. Checks and money orders should be made payable to "Social Security Administration". I f paying by credit card, please provide the following:
Type of Credit Card: _______________________________________________
Card Holder's Name and SSN: _______________________________________
Card Holder's Address: ____________________________________________
Daytime Phone Number: ____________________________________________
Amount to be charged: ______________________________________________
Credit Card Number: ______________________________________________
Month and Year of Expiration:_________________________________________