Form SSA-702 Statement Regarding Date of Birth and Citizenship

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0016

TOE 420

(Do not write in this space)

STATEMENT REGARDING DATE OF BIRTH AND CITIZENSHIP
This report is authorized by section 205(a) of the Social Security Act, as
amended (42 U.S.C. 405(a)). While your response is voluntary, your
cooperation is needed to help us make a determination about the date of
birth and/or citizenship of the person named below.
All items on this form requiring an answer must be answered or marked "Unknown."

/
(Name of wage earner, self-employed person, or SSI applicant)

I,

(Name of person making this statement)

/

(Social Security Number)

, understand that the information I give will be used with

an application for benefits payable under the Social Security Act.
1. Give full name of person about whom this statement is made: 2. How many years have you known this
person?
3. When was he or she born? (Month, day, year)

4. Where was he or she born? (City or county--State
or foreign country)

5. How did you learn about this person's date of birth? (Tell fully how you know when this person was born.)

6. How are you related to this person? (If not related, write "None.")

7. When and Where
Were YOU
Born?

MONTH-DAY-YEAR

CITY OR COUNTY

STATE OR FOREIGN COUNTRY

I know that anyone who makes a false statement or representation of a material fact in an application or for use in
determining a right to payment under the Social Security Act commits a crime punishable under Federal and/or State law
by fine, imprisonment or both. I affirm that all information I have given in this document is true.
SIGNATURE OF PERSON MAKING STATEMENT
Signature (First name, middle initial, last name) (Write in ink)

Date (Month, day, year)

SIGN
HERE

Telephone Number (Include area code)

Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)
City and State

ZIP Code

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses
to the signing who know the person making the statement must sign below, giving their full addresses.
1.

Signature of Witness

2.

Address (Number and Street, City, State and ZIP Code)

Form SSA-702 (08-2009)

EF (08-2009)

Destroy Prior Editions

Signature of Witness
Address (Number and Street, City, State and ZIP Code)

Privacy Act Statment
Collection and Use of Personal Information
Sections 205(a) and 1631 (e)(1)(A) and (B) of the Social Security Act, as amended, authorize us to collect this
information. The information you provide will be used to help establish age and/or citizenship.

See below for

The information you furnish on this statement is voluntary. However, failure to provide the requested information may
Privacy
prevent an accurate and timely decision on any revised
claim filed,
or couldAct
result in the loss of benefits.

and Paperwork
We rarely use the information you supply on thisReduction
statement for
any purpose other than for the stated purpose of
Act
establishing age and/or citizenship. However, weStatements.
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 and audit activities necessary to assure the integrity and improvement of
Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social
Security).
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.
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.

Paperwork Reduction Act (PRA) 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.

Form SSA-702 (08-2009)

EF (08-2009)

Destroy Prior Editions

Statement Regarding Date of Birth and Citizenship, Form SSA-702
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 1631(e)(1)(A) and (B) of the Social Security Act, as amended,
[42 U.S.C. 405(a)] and [42 U.S.C. 1383(e)(1)(A) and (B)] authorize us to collect this
information. We will use the information you provide to help us establish age and or
citizenship.
The information you provide on this form is voluntary. However, failure to provide
the requested information may prevent an accurate and timely decision on any claim
filed, or could result in the loss of benefits.
We rarely use the information you provide on this form for any purpose other than for
the reasons explained above. 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, including but
not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to
Social Security benefits and or coverage;
2. To comply with Federal laws requiring the release of information from our
records (e.g., to the Government Accountability Office, General Services
Administration, National Archives Records Administration, and the
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 our programs (e.g., to the U.S.
Census Bureau and to private entities under contract with us).
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. We use the information from these programs to establish
or verify a person’s eligibility for federally-funded or administered benefit programs
and for repayment of incorrect payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our
systems and programs, is available on-line at www.socialsecurity.gov or at any 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 OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.