Form SSA-L706 Letter to Custodian of Birth Records

Form Approved

Social Security Administration
LETTER TO CUSTODIAN OF BIRTH RECORDS

OMB No. 0960-0693

Claim Number : ____-___-_______________
Date: _____________________
Custodian of Record: Please complete, sign and date part 5 of this form, include your seal if
you have one, and return the form to requester/SSA.
PART 1 - TO BE COMPLETED BY REQUESTER
Sir/Madam:
I/the Social Security Administration (Circle One) need(s) to establish a date of birth for SSA
purposes. I request a certified copy/certification/verification (Circle One) of your record showing
the date of birth based on:
_____ The information below; or
_____ The document attached.
Full Name at Birth

Sex

Date of Birth (Month, Day, Year)
Place of Birth (City, County, and State)
Mother's Maiden Name (First, Full Middle, Last)
Father's Name (First, Full Middle, Last)

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

Address

Print Full Name

Relationship to Above Person (e.g., Self, Authorized Applicant)

(

)

-

Phone Number with Area Code

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

Form SSA-L706-F3 (07-2009) Issue old stock

Page 1

LETTER TO CUSTODIAN OF BIRTH RECORDS
PART 3 - PAYMENT INFORMATION
Enclosed is $
in the form of:
o Personal Check
o Certified Check
o Money Order
o Credit Card (Type, Number, Expiration Date)
o No Fee Required
o Other
DO NOT SEND CASH.
PART 4 - COMPLETED BY SSA OFFICIAL TO INDICATE RETURN ADDRESS/TO
VERIFY REQUESTER'S IDENTITY

Signature

Social Security Office Name

Print Name and Title

Office Address

(

)

-

Office Telephone Number with Area Code

Extension

Verification of Requester's Identity (If Required)
I verified the requester's identity. The requester submitted the following as evidence of his/her identity:
PART 5 - TO BE COMPLETED BY RECORDS CUSTODIAN OR OFFICIAL
Choose option A, B, or C.

A. ‰ Certified Birth Record Attached
B. ‰ Certification/Verification of Birth Record
‰ I verify the information on the document submitted.
‰ I certify the information provided below.
Name As Shown on the Record __________________________________________________
Type of Birth or Religious Record ________________________________________________
Date of Birth or Age ___________________________________________________________
If Age, As of Which Birthday? ‰ Last

‰ Next

‰ Nearest

‰ Not Given

Date of the Record _____________________________________________________________
Place of Birth _________________________________________________________________
Mother's Full Name ____________________________________________________________
Father's Full Name _____________________________________________________________
Remarks _____________________________________________________________________
Form SSA-L706-F3 (07-2009)

Page 2

LETTER TO CUSTODIAN OF BIRTH RECORDS
C. ‰ Negative Certification/Verification
I searched for a birth/religious (Circle One) record for the person named in Part 1 and found no record for
him/her for the year(s)
D. ‰ Signature and Seal
Please sign and date, indicate your title, provide address, and affix seal if you have one or indicate that no seal
exists. Return to requester or SSA, as indicated on page 1.
Signature _____________________________

Address ______________________________

Title _________________________________

______________________________________

Date _________________________________

______________________________________

No Seal __________

______________________________________

Affix Seal →

See Revised Privacy Act
Statement
Privacy Act - 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 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 1-800-772-1213 (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.
See Revised Paperwork
Reduction Act Statement

Form SSA-L706-F3 (07-2009)

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.