SSA-702 Statement Regarding Date of Birt and Citzenship

STATEMENT REGARDING DATE OF BIRTH AN D CITIZENSHIP
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See Re~ised PnvflCY Al;t
Stfltement Attached

The infQmumon
ested on thi, ml is autbonzcd t th e 50(:111 Sec uril Act, SectIon
20S(a)andby T II 2OCfH404.76 Theinformll!lO providoo will beu ,.j tohelp
ffilbltsh age an or citizenshIp.
hile providillg t infon natio n req
on (hI S fonn
is vOIUnllll)'. ~ , ure to plOVlde i forma tion t":1< COU help establish nBe ndlor
ci tilenshtp 11 y pre vent an
te and tim ely d SIIl II on any claIm fi eJ or it could
resu lt In th e """ of~me bene 11.. III IOWrattCe co "'ge Any info
on prt)",doo .... ill
bowme
of the dalJIlS fil WhIle the info
110n furnished o n th fonn wo ul,1
a lmost
'er be u'l<>d (3) 10 comp with the IDW5 a mi
u l ~ tlons reqtllIln¥ Ih CJ(chauge of info
a lion belwl...,n S5A
all()lh~'1' Rlleney
PaJ>f'r"'ork Rtductio ll Ad ( I'RAJ

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inf"m,ation co lle-ct lon mcclS tN: r~' OR BRING TBE CO.\ 11'L ETED FORI\! TO YOUR
LOCAL SOCIA L S J:C URITY OFfiCE. Th~ office h listed und~r U.S. GIlVtrnm t ni
agcllfj('S in your IcI ~p/tonc dlrc~Ior) or )(\u may cill Sod.1 S« urit y II ' ·800-772­
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