Certification of Prison Records by Prison Officials

Certification of Prison Records by Prison Officials

OMB Certification Template 11_2009

Certification of Prison Records by Prison Officials

OMB: 0960-0688

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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

File Typeapplication/msword
File TitleExhibit B
AuthorTSapia
Last Modified ByMandley, Tasha
File Modified2009-11-17
File Created2009-11-17

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