Form SSA-L106 Letter to Custodian of School Records

FORM APPROVED
SOCIAL SECURITY ADMINISTRATION

OMB No. 0960-0693

LETTER TO CUSTODIAN OF SCHOOL RECORDS
Claim Number
Date
PART 1 – TO BE COMPLETED BY REQUESTER

Name of Record Custodian
Address of Record Custodian

Sir/Madam:
I need to establish my date of birth to become entitled to Social Security benefits. I am requesting
verification of my age according to records that may be available at your school. I am providing the
following information to help in searching your records.
Name as Registered in School

Nickname

Date of Birth (Month, Day, Year)

Place of Birth (City, County, and State)

Name(s) of Parent(s) or Guardian(s) (First, Full Middle, Last)
Schools Attended (In same city or school district)
(1) Name of School (If unable to remember, give location)

Grade(s) Attended

Date(s) Attended

Grade(s) Attended

Date(s) Attended

Residence at Time of Attendance

Remarks

(2) Name of School (If unable to remember, give location)

Residence at Time of Attendance

Remarks

Form SSA-L106-F3 (9/2008)
(3-2005) Destroy
Recycle Prior Editions

Page 1

LETTER TO CUSTODIAN OF SCHOOL RECORDS

(3) Name of School (If unable to remember, give location)

Grade(s) Attended

Date(s) Attended

Residence at Time of Attendance

Remarks

I authorize the disclosure of the requested information to the Social Security Administration.

Signature

Address

Print Full Name

Phone Number with Area Code
Relationship to Person Whose Record is Being Requested

PART 2 – NOTARIZATION OF REQUESTER’S SIGNATURE (If Required)
Notary Public should use the space below for notarization and placement of seal.

PART 3 – PAYMENT INFORMATION
Enclosed is $

in the form of:

Personal Check
Certified Check
Money Order
No Fee Required
O
OtherSEND CASH.
DO NOT

_______________
DO NOT SEND CASH

Form SSA-L106-F3 (3-2005)
Recycle Prior Editions
(9/2008) Destroy

Page 2

LETTER TO CUSTODIAN OF SCHOOL RECORDS
PART 4 – CERTIFICATION BY CUSTODIAN OF SCHOOL RECORDS

➢

The record is unavailable.

➢

I certify the information below based on school records in my custody.
Name of School
Address of School
Name as Shown on School Record
Name(s) of Parent(s) or Guardian(s)
Age or Date of Birth as Shown on School Records
Date of School Record (Month, Day, Year)
Place of Birth
Remarks

Signature and Title of Custodian of School Records

Name of School or Agency Having Custody of Record

Address (Street, City, State, Zip Code)

Date

See Revised Privacy Act
Statement

PRIVACY ACT/PAPERWORK REDUCTION ACT NOTICE
The Privacy Act requires us to notify you that we are authorized to collect this information by section 205(a) of the Social Security
Act. You do not have to provide the information requested. The data you provide, however, will allow the Social Security
Administration to determine the age and/or citizenship of a person who is applying for Social Security or Supplemental Security
Income benefits. If you do not complete this form, that person may not be entitled to benefits. We do not disclose the information
you provide to any person or other government agency.
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 to 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 give 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.
Paperwork Reduction Act 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 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 1-800-772-1213.(TTY
You
may send commentsYou
on our
time
estimate
above to:
Building,
21235-6401.
Send only
comments
may
send
comments
onSSA,
our 1338
time Annex
estimate
aboveBaltimore,
to: SSA,MD
6401
Security Blvd.,
Baltimore,
MD
1-800-325-0778).
relating to our Send
time estimate
to this address,
not the
21235-6401.
only comments
relating
tocompleted
our time form.
estimate to this address, not the completed form.

See Paperwork Reduction
(9/2008) Recycle
Destroy Prior Editions Act Statement Statement
Form SSA-L106-F3 (3-2005)

Page 3

SSA will insert the following revised Privacy Act Statement into the form
at its next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information

Section 205(a) of the Social Security Act, as amended, authorizes us to collect this
information. We will use the information you provide on this form to determine the age
and/or citizenship of a person who is applying for Social Security or Supplemental
Security Income benefits.
Completion of this form is voluntary; however, if you do not complete this form, it may
delay the determination of your eligibility for benefits..
We rarely use this information you supply for any purpose other than for determining
continuing eligibility. However, we may use it for the administration and integrity of
Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not
limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights
to Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social
Security records (e.g., to the Government Accountability Office and Department
of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to
assure the integrity and improvement of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local
government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally-funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Records
Notices entitled, Claims Folders Systems (60-0089) and the Master Beneficiary Record
(60-0090). The notices, additional information regarding this form, routine uses of
information, and our programs and systems is available on-line at
www.socialsecurity.gov or at your local Social Security office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act 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 only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.