Form SSA-711 Request for Deceased Individual's Social Security Record

OMB NO. 0960-0665

REQUEST FOR DECEASED INDIVIDUAL’S SOCIAL SECURITY RECORD
*Use This Form If You Need

1. Photocopy of Original Application for a Social Security Card (SS-5).
OR
2. Computer extract of Social Security Card Application.
“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 7 minutes to read the instructions, gather the facts, and answer the questions. Send only comments on our time estimate above to: SSA,
1338 Annex Building, Baltimore, MD 21235-6401.”

See Revised PRA Attached

INFORMATION ABOUT YOUR REQUEST
¡ How Do I Get This Information?
Complete page 2 of this form to tell us what information you want. Photocopy page 2 for
multiple requests.
¡ Is There A Fee For This Information? Yes
Photocopy of Original Application for Social Security Card (SS-5)
If SSN of deceased individual is provided, the fee is $27.00.
If SSN of deceased individual is not provided, the fee is $29.00.
Computer Extract of SS-5 (May not contain the names of the individual’s parents and the place of birth)
If SSN of deceased individual is provided, the fee is $16.00.
If SSN of deceased individual is not provided, the fee is $18.00.
Certified copy is provided for an additional fee of $10.00 (See instructions below)
¡ SSN Search required.
Complete as much information as possible in Blocks 4 and 5, if the deceased individual’s
SSN is unknown.
¡ When Is Certification required?
Certification is usually not necessary unless you plan to use the information in court.
¡ Method of Payment.
Payment can be made with a credit card by completing the attached Form SSA-714 and
returning it with your request(s) form. You may also pay with a check or money order
(Name, Address and Phone Number must appear on Check). Enclose one check or money
order for the entire fee required (total from request(s)). DO NOT SEND CASH.

FORM SSA-711 (03-2005)

REQUEST FOR DECEASED INDIVIDUAL’S SOCIAL SECURITY RECORD
PROCESSING LIMITATIONS: A Request for information CANNOT be processed for:
INDIVIDUALS WHO DIED BEFORE NOVEMBER 1936.
INDIVIDUALS BORN BEFORE 1865 (unless you furnish a Social Security Number (SSN)).
INSTRUCTIONS: PRINT OR TYPE ALL DATA. SIGN IN INK. ALLOW 4-6 WEEKS FOR A REPLY.
If you have any questions regarding completion of this form call 1-800-772-1213.
1.

2.

3.

Request for photocopy of Original Application for Social Security Card (SS-5).
Enter, $27.00, if SSN of deceased individual is provided .......................................................................................

A. $ ___________

Enter $29.00, if SSN of deceased individual is not provided ..................................................................................

B. $ ___________

Request for Computer extract of Social Security Number Application.
Enter, $16.00, if SSN of deceased individual is provided .......................................................................................

C. $ ___________

Enter, $18.00, if SSN of deceased individual is not provided .................................................................................

D. $ ___________

If Certification is required, enter an additional $10.00 ............................................................................................

E. $ ___________

Add the amounts from Lines A through E and enter TOTAL on Line F ..................................

F. $ ___________
Paying with a CREDIT CARD, complete and return Form SSA-714 attached, or
Enclose your CHECK or MONEY ORDER for the amount on line F payable to “Social Security Administration.”

4.

DO NOT SEND CASH. DO NOT SEND SELF-ADDRESSED STAMPED ENVELOPE.
DECEASED INDIVIDUAL’S INFORMATION (COMPLETE AS MUCH INFORMATON AS POSSIBLE)

Name of Individual at birth (first, middle, last name)

Name(s) of Individual (if other than above/other name(s) used)
M
Social Security Number

Date of birth (mo, day, yr)

F

Circle Sex

Place of Birth (City, State or Foreign Country)
5.

DECEASED INDIVIDUAL’S PARENTS’ INFORMATION (if SSN of deceased individual is not provided, please complete this section)
(Complete as much information as possible)

Mother’s (Maiden) Name at birth (first, middle, last name)

Mother’s married name(s)

Father’s Name (first, middle, and last name)
6.

REQUESTER’S INFORMATION (PLEASE READ PRIVACY ACT STATEMENT BEFORE COMPLETING THIS SECTION)

Printed Name of Requester (first, middle, last name)

Signature (do not print unless this is your usual signature)

Date

Street Address
(
)
Telephone Number
8.

Forward Request to:

City, State and Zip Code
(
)
Fax Number

SSA OEO DERO FOIA
PO BOX 33022
BALTIMORE MD 21290-3022

E-Mail Address
9.

FORM SSA-711 (03-2005)

2

Forward Express Mail to:

SSA OEO DERO FOIA
300 N GREENE ST
BALTIMORE MD 21290-0300

REQUEST FOR DECEASED INDIVIDUAL’S SOCIAL SECURITY RECORD
*Use this form only if you need (1) a photocopy of the original application for a Social Security Card (SS-5) or (2) a
computer extract of the Social Security Card Application. See Revised PRA Attached
“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 7 minutes to read
the instructions, gather the facts, and answer the questions. Send only comments on our time estimate above to: SSA,
1338 Annex Building, 6401 Security Boulevard, Baltimore, Maryland 21235-6401.”

INFORMATION ABOUT YOUR REQUEST
o

How Do I Get This Information? Complete page 2 of this form to tell us what information you want. Photocopy
page 2 for multiple requests.

o

Is There A Fee For This Information? Yes.
Photocopy of Original Application for Social Security Card (SS-5)
If SSN of deceased individual is provided, the fee is $27.00.
If SSN of deceased individual is not provided, the fee is $29.00.
Computer Extract of SS-5 (may not contain the names of the individual’s parents and the place of birth)
If SSN of deceased individual is provided, the fee is $16.00.
If SSN of deceased individual is not provided, the fee is $18.00.
Certified copy is provided for an additional fee of $10.00 (See instructions below).

o

SSN Search required.
Complete as much information as possible in Blocks 4 and 5, if the deceased individual’s SSN is unknown.

o

When is Certification required?
Certification is usually not necessary unless you plan to use the information in court.

o

Method of Payment.
Payment can be made with a credit card by completing the attached Form SSA-714 and returning it with your
request(s) form. You may also pay with a check or money order (Name, Address and Phone Number must
appear on Check). Enclose one check or money order for the entire fee required (total from request(s)). DO
NOT SEND CASH.

PRIVACY ACT STATEMENT
Collection and Use of Personal Information
See Revised Privacy Act Statement Attached

The Freedom of Information Act at 5 U.S.C. § 552 and our regulations at 20 C.F.R. § 402.130 authorize us to collect the
information on this form. The information you provide will be used to respond to your request for SSA records information
and may be used to facilitate statistical research, audit, or investigative activities necessary to ensure the integrity of SSA
programs. Your response is voluntary; however, failure to provide all or part of the requested information could prevent us
from being able to accurately respond to your request.
We rarely use the information provided on this form for any purpose other than to respond to requests for SSA records
information. However, in accordance with 5 U.S.C. § 552a(b) of the Privacy Act, we may disclose the information
provided on this form (1) to comply with Federal laws requiring the disclosure of the information from our records; (2) to a
Congressional office requesting information on your behalf; (3) to the Department of Justice (DOJ) for use in representing
the Federal Government; and (4) to the General Services Administration and the National Archives and Records
Administration to conduct studies.
A complete list of routine uses of this information is contained in our System of Records Notice 60-0340 (Electronic
Freedom of Information Act (e-FOIA) System). Additional information regarding this form and our other systems of
records notices and Social Security programs are available from our Internet website at www.socialsecurity.gov or at your
local Social Security office.

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:

PRIVACY ACT STATEMENT
Collection and Use of Personal Information
The Freedom of Information Act at 5 U.S.C. § 552 and our regulations at 20 C.F. R. § 402.130
authorize us to collect this information. We will use this information to respond to your request.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may prevent us from accurately responding to your request.
We rarely use this information for any purpose other than to respond to requests for our
information. 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 a Congressional office requesting information on your behalf;
2. To the Department of Justice (DOJ) for use in representing the Federal Government;
3. To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office and the Department of Veterans’
Affairs);
4. To facilitate statistical research, audit and investigatory activities necessary to assure the
integrity and improvement of Social Security programs.
A complete list of routine uses of this information is available in our Privacy Act Systems of
Records Notices, 60-0340, Electronic Freedom of Information Act (eFoia) System. This notice,
additional information regarding our programs and systems, are available online at
www.socialsecurity.gov or at any local 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
(OMB) control number. We estimate that it will take about 7 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.