Form SSA-702 Statement Regarding Date of Birth and Citizenship

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMS No. 0960-0016

TOE 420

(Do not write in this space)

STATEMENT REGARDING DATE OF BIRTH AND CITIZENSHIP
This report is authorized by section 205(a) of the Social Security Act, as
amended (42 U.S.C. 405(a)). While your response is voluntary, your
cooperation is needed to help us make a determination about the date of
birth and/or citizenship of the person named below.
All items on this form requiring an answer must be answered or marked "Unknown."

Change to selfemployed.

(Name of wage earner, self-employer person, or SSI applicant)

1,

_
(Name of person making this statement)

(Social Security Number)

, understand that the information I give will be used with

an application for benefits payable under the Social Security Act.
1. Give full name of person about whom this statement is made: 2. How many years have you known this
person?
3. When was he or she born? (Month, day, year)

4. Where was he or she born? (City or county--State
or foreign country)

5. How did you learn about this person's date of birth? (Tell fully how you know when this person was born.)

6. How are you related to this person? (If not related, write "None.")

7. When and Where
Were YOU
Born?

MONTH-DAY-YEAR

CITY OR COUNTY

STATE OR FOREIGN COUNTRY

I know that anyone who makes a false statement or representation of a material fact in an application or for use in
determining a right to payment under the Social Security Act commits a crime punishable under Federal and/or State law
by fine, imprisonment or both. I affirm that all information I have given in this document is true.
SIGNATURE OF PERSON MAKING STATEMENT
Signature (First name, middle initial, last name) (Write in ink)

Date (Month, day, year)

SIGN ~

Telephone Number (Include area code)

HERE
Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)

IZIP Code

City and State

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses
to the signing who know the person making the statement must sign below, giving their full addresses.
1.

Signature of Witness

Address (Number and Street, City, State and ZIP Code)

Form SSA-702 (9-1982 EF 6-2000)

2.

Signature of Witness

Address (Number and Street, City, State and ZIP Code)

Privacy Act Statement
The information requested on this form is authorized by the Social Security Act, Section
205(a) and by Title 20 CFR 404.716. The information provided will be used to help
establish age and/or citizenship. While providing the information requested on this form
is voluntary, failure to provide information that could help establish age and/or
citizenship may prevent an accurate and timely decision on any claim filed or it could
result in the loss of some benefits in insurance coverage. Any information provided will
become part of the claims file. While the information furnished on this form would
almost never be used for any purpose other than making a determination about
entitlement to benefits, such information may be disclosed by SSA for the following
purposes: (1) to assist SSA in determining the right to Social Security benefits; (2) to
facilitate statistical research and audit activities necessary to assure the integrity and
improvement of programs administered by SSA; and (3) to comply with the laws and
regulations requiring the exchange of information between SSA and another agency.
Paperwork Reduction Act (PRA) 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. The office is listed under U.S. Government
agencies in your telephone directory or you may call Social Security at 1-800-7721213 (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.