SSA-L106 (Current)

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

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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

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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
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Building,
21235-6401.
Send only
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Security Blvd.,
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See Paperwork Reduction
(9/2008) Recycle
Destroy Prior Editions Act Statement Statement
Form SSA-L106-F3 (3-2005)

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