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

F O R M APPROVED
O M n No. 09604689

TOE 420

CERTIFICATION OF CONTENTS OF DOCUMENT(S1OR RECORD(S1

SOCIAL SECURITY ADMINISTRATION

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SOCIAL SECURIN NUMBER

N A M E O F NUMBER HOLDER

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EXTRACT TRANSLATION OF 1Spscityl

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~ a n g v a o eoocurnenc
E v e r y i t e m i n a b l a c k m u s t b e filled o u t w i t h E X A C T EXCERPTS f r o m t h e d o c u m e n t c s n i f i e d or t h e i t e m m u s t b e m a r k e d 'NS" or ' N o t shown.'' I f t h e d a t e on w h i c h
an e n t r y Was m a d e i n a f a m i l y r e c o r d i s 'not shown.' i n d i c a t e u n d e r 'Remarks' a n y a l l e g a t i o n es t o w h e n r h e d o c u m e n t or r e c o r d w a r established. I n c l u d e a n y Other
~ e n i n e n itn f o r m a t i o n s h o w n on t h e d o c u m e n t u n d e r 'Remarks." Cross out all u n u s e d blocks. le.0.. i f a c e n i f i c a t o n i s m a d e o n l v i n b l o c k ' A l . " crass out 'A2." ' 8.'
'C.'
OD,' a n d 'E "I

A. AGE, RELATIONSHIP OR CITIZENSHIP OF:
1

ISEX

NAME OF PERSON A S SHOWN ON EVIDENCE

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AGE

ONDT
SHOWN

NOT GIVEN

BIRTHDAY AGE SHOWN

q LAST

q

NEXT

DATE OF BlRTH

MALE

1

q FEMALE
q NOT SHOWN

N A N R E OF EVIDENCE

NOT SHOWN

NOT SHOWN

CUSTODY OF DOCUMENT
APPLICANT
R E C O R D CUSTODIAN
O T H E R ( R e l a t i o n s h i p to Applicant1

1

DATE RECORDED Bf d i g i i u s m i i i d , show date of
ceremonrl
-

NEAREST

NAME OF FATHER

PLACE OF BlRTH

AGE

q NOT SHOWN

NAME OF MOTHER

AGE

DATE OOCUMENT 1SSUED llf cenifyng fmm a
PUBLIC
DOCUMENT NO.
CU~TODIAN mc give dsre ofpublicsfion orlssr copyright, and
C.rnOblBIUlr7 El

NAME AN0 AOORESS OF ISSUING AGENCY IF NOT A WBLlC RECORD
linclude ZIP Cedal

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2.

NAME OF PERSON AS SHOWN ON EVIDENCE

SEX

PLACE OF BIRTH

DATE OF BlRTH

MALE
FEMALE

q NOT SHOWN
BIRTHDAY AGE SHOWN

AGE

DATE RECORDED lrrreIigiouS oecsrd, showdate of
cersmon"1

NOT GWEN

Q;WN

q LAST

q

NOTSHOWN
NEXT

NEAREST

U NOT SHOWN

NAME OF FATHER

AGE

I

CUSTODY OF DOCUMENT
q APPLICANT
R E C O R D CUSTODIAN
q O T H E R ( R e l a t i o n s h i D to
-

NATURE OF EVIDENCE

NOT SHOWN

NAME OF MOTHER

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AGE

I

A P. D
. licantl
DATE DOCUMENT ISSUED llf cenifW7g fmm s
DOCUMENT NO.
PUBLIC
CUSTODIAN Bible, give date of oublicaCiOn or last copYr;ght, and

NAME AN0 ADDRESS OF ISSUING AGENCY IF NOT A PUBLIC RECORD
I;nrlude ZIP Codel

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B. MARRIAGE OF:

IDATEOF BIRTH

IPREVIOUS
MARRIAGES

NAME OF HUSBANO A S SHOWN ON EVIDENCE

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10. 1. 2, ets.1
NOT
SHOWN
DATE OF BIRTH

PREVIOUS MARRIAGES
10, 1. 2. etc.1
NOT
SHOWN

NAME OF WIFE AS SHOWN ON EVIDENCE

l~~~ IBIRMDAYAGE SHOWN

I I
AGE

NEXT

NEAREST
NOTGIVEN

BIRTHDAY AGE SHOWN

q LAST

NEAREST

q NEXT

q

NOTGIVEN

MARRIAGE CERTIFICATE PLACE OF

NATURE OF EVIDENCE

n
- BIBLE homo,ete
.~~ .
.
~

~

~

El

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'DATE OF MARRIAGE

CUSTODY OF DOCUMENT

qA P P L I C A N T

q
q

q LAST

q

RECORD
CUSTODIAN

OTHER (Relationship
t o Applicant1
WBLlC
DOCUMENTNO.
CUSTODIAN

NAME AND ADDRESS OF ISSUING AGENCY IF NOT A PUBLIC RECORD llncludcZIP Codel

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C. DEATH OF:
DATE OF DEATH

NAME OFOECEASED AS SHOWN ON EVIDENCE

---.
-

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CUSTODY OF DOCUMENT
-TL,cm
:RECORD
u nmcn t,m-,..:
-emmxmurm=nmmv
APPl.CnhT
C J S T O D A h O t o Apolcanl,
\&ME A h 0 ADDRESS OF SSr h G aGEhCV F hOT b P.B.

FORM

SSA-704F3 1 0 9 - 2 0 0 5 1 EF 1 0 9 - 2 0 0 5 1

CAUSE OF DEATH

PLACE OF DEATH

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NATURE OF EVIDENCE

DEATH

PUBLIC
OOCUMENT NO.
CUSTODIAN

C RECORD .,om8 UeZ,PCoUa,

(OVER)

0. SERVICE IN U.S. ARMED FORCES OF:
NAME OF PERSON A S SHOWN ON EVIDENCE
RANK

SERIAL NO.

BRANCH Umv, Navy, etr.1

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DATE ENLISTED OR

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EVIDENCE

INDUCTED

ORIGINAL DISCHARGE

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DATE ENTERED ACTIVE D U N

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MEANS OF ENTRY INTO
SERVICE

OATE BIRTH OR AGE RECORDED

NATURE OF

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INDUCTED

DATE OF BIRTH OR AGE

DATE DISCHARGED OR RELEASED FROM ACTIVE D U N

CALLED FROM INACTIVE DUTY

ENLlSED

RE-ENLISTED

COMMISSIONED

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CHARACTER OF

DISCHARGE:
OHONORABLE

REASON bND AUTHORIN FOR SEPARATION

NOTSHOWN

OTHER B#ScdbeI
PERSON

SUBMlTnNG DOCUMENT. RELATIONSHIP TO

APPLICANT. AND ADDRESS

lindude ZIP Codel

NAME AND ADDRESS OF ISSUING l G E N C Y IF NOT A PUBLIC RECORD lincludeLIP Cadei

APPLICANT

CUSTODIAN DATE DOCUMENT ISSUED

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DOCUMENT NO.

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

3.

RELATIONSHIPTO CLIIMANT

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4. DATE ENTRY MIDE

2. ADDRESS 1;nsbdeZIP Codel

Examination of record.
Does entire entry appear to have been made bv the same parson at the rams time?
2. Is record mads in:
q Ink
Pencil
Ballpoint Pen
Other
3. Describe the condition of the paper lyeliow, brinie, ere.), and the condition of the book:

Yes

1.

4.

5.
6.
7.

-.

No (Erplan in Remarks1

ISentry faded?

Yell
No
Does entry appear to be:
Old
Rstanr
Date Bible printed or putdishad.
it photocopy cannot be submitted, answer the following:
a. Are entries arranged chronologically?
Yall
No lExp/ain ;n Rema&
b. Name and date as shown in the sotry immediately before and immediately after the entry for the claiment:

8. a.

b.

Enav before
Who has had custody of the record?

Emrv after
C.
When war the entry made?

Who made the entry)

d.

F. REMARKS:

HOWdoes the claimant know this?

NOTE: -Do not usa this form to abstract from any coun order ie.g., divorce, annulment and edoption decrees, st=.) or to esnity the
contents of any foreign inon-Enptirhl language document unless you are an authorized SSA trmslator.

CERTIFICATION: - i have personally examined the documents end records above and CERTIFY their contents in connection w i t h en application
for benefits under Title 11. T i l e XVI, endlor Title XVlll of tha Social Security Act, as amended. Unless otherwise stated, ell the entries herein ere
exact excerpts from such documents or records. The entries are free t m m erasures, interlineation. or other alteretions and the general
appeerence of the documents or recorde satisfactorily establish their authenticity. The entries (in the case o f original records1 appear t o heve
been made at tha time the record was purportedly established. and there is no reason t o doubt the validity o f the records or entries, unless
otherwise stated and explained under 'Remarks.SIGNATURE

'

CLAIMS
REPRESENTATIVE

DATE

'

SERVICE

SENIOR CLAIMS

REPRESENTATIVE

SPECIALIST

FORM SSA-704-F3 (09-20051 EF 109-2005)

QUALIWASSURANCE
SPECIALIST

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Privacy Act Statement
The information requested on this form is authorized by the Social Security Act, Sections
205(a), 163a(e)(l)(A) and (B), and 1631( f ) , and Title 2 0 CFR 404.707. The information
provided will allow Social Security Administration to determine eligibility factors. This is
in situations where obtaining photography of an original or certified document is not
possible. You do not have to provide the information requested. However, the data you
provide will allow the Social Security Administration to determine eligibility factors of the
person who is applying for Social Security or SSI benefits. If you do not complete this
form, that person may not be entitled to benefits. The information you furnish may be
disclosed by SSA for the following purposes (1) to assist SSA in determining the right to
Social Security benefits for the applicant or another person; (2) to facilitate statistical
research and audit activities necessary t o assure the integrity and improvement of
programs administered by SSA, and (3) to comply with laws and regulations requiring
the exchange of information between SSA and another agency.
P

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 t o 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 provide 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.

r-

Paperwork Reduction Act Statement - This information collection meets the requirements
of 4 4 U.S.C. 9 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 1 0 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 i n 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, 640 1 Security Blvd., Baltimore, MD 2 1235-6401. Send only
comments relating to our time estimate to this address, not the completed form.

FORM SSA-704-F3 109-2005) EF 109-20051

G;D U S . GOVERNMENT PRINTING OFFICE: mS32&638/m579