Certification of Prison Records by Prison Officials

DATE: _______________________

NAME: _______________________

INMATE ID #: _________________

SOCIAL SECURITY #:____________

Social Security Administration

(address)

(location)

Attached, please find a completed Form SS-5 (Application for Social Security Number) requesting a replacement Social Security number card for the above named individual.

I, the undersigned, certify that I have reviewed the above inmate's official prison record and that the identifying information shown below is accurate according to that record.

NAME _________________________________

DATE OF BIRTH _________________________________

PLACE OF BIRTH _________________________________

MOTHER'S MAIDEN NAME _________________________________

FATHER'S NAME _________________________________

If you have any further questions, please contact me between the hours of ______ to ______. My telephone number is _____________.

_____________________________

(title)

(prison name, city)

OMB Control Number 0960-0688