Form SSA-L707 Request for Proof(s) from Custodian of Records

Form Approved
OMB No. 0960-0766

Social Security Administration

REQUEST FOR PROOF(S) FROM CUSTODIAN OF RECORDS
Unit Number: _________________________

DATE:
Number Holder: __________________________

TO:

CUSTODIAN OF RECORDS

___________________________________
Address
___________________________________
Address
___________________________________
City
State
ZIP Code

• Please furnish a certified copy of your record or a Letter of No Record of the following
event(s):
Marriage
Divorce
Death
See page 2 for details. Include this form with your response.
• Verification of Requester's Identity (if required)
Proof of the requester's identity is attached.
•The document is needed for Social Security Administration purposes.
• Enclosed is $ _____________________ in the form of:
Personal Check
Certified Check
Money Order
Credit Card (Type, Number, Expiration Date, Name as shown on
card) _______________________________________________________
Other (specify) _____________________________________________
No Fee Required
Do not send cash.
• Please send the document(s) to (check one):
OR

The Social Security Office

My address below
(Please Print)

(Please Print)
Social Security Administration
Attention: ________________________
___________________________________
Address
___________________________________
Address
___________________________________
City
State
ZIP Code

Name _____________________________
___________________________________
Address
___________________________________
Address
___________________________________
City
State
ZIP Code

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

RELATIONSHIP TO PERSON
ON RECORD

SIGNATURE OF REQUESTOR

Form SSA-L707 (08-2010) EF (08-2010)
Destroy Prior Editions

•The following information may assist you in locating the correct record:
DEATH RECORD
Full Name of Deceased (first, middle, last) _________________________________________________
Date of Death (month, day, year) _________________________________________________________
Sex _____________________________ State of Birth _______________________________________
Place of Death (city, county if known, state) ________________________________________________
• If unable to locate record, please indicate years searched and sign. ________________________________
MARRIAGE RECORD
Name of Groom or Party 1 (first, middle, last) _______________________________________________
Date of Birth (month, day, year) __________________________________________________________
Place of Birth _________________________________________________________________________
Name of Bride or Party 2 (first, middle, last) _________________________________________________
Date of Birth (month, day, year) __________________________________________________________
Place of Birth _________________________________________________________________________
Date of Marriage (month, day, year) _______________________________________________________
If date unknown, year(s) to be searched ____________________________________________________
County that issued license _______________________________________________________________
County and state where marriage occurred __________________________________________________
If checked, please include age or birth date of _____________________ as shown on the marriage record.
• If unable to locate record, please indicate years searched and sign. ________________________________
DIVORCE RECORD
Name of Husband or Party 1 (first, middle, last) _______________________________________________
Date of Birth (month, day, year) __________________________________________________________
Name of Wife or Party 2 (first, middle, maiden)_______________________________________________
Date of Birth (month, day, year) __________________________________________________________
Date of Divorce (month, day, year) _______________________________________________________
If date unknown, year(s) to be searched ____________________________________________________
County and state where divorce occurred __________________________________________________
• If unable to locate record, please indicate years searched and sign. ________________________________
Privacy Act Statement - Section 205(a) of the Social Security Act as amended [42 U.S.C. 405(a)], authorizes us to collect this information.
The information you provide will allow us to determine eligibility for benefits of a person who is applying for Social Security or Supplemental
Security Income benefits. Your response is voluntary, however, your failure to complete this form may prevent us from making an accurate or
timely decision on the named person's eligibility for 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, which include
are not limited to the following: 1. To enable a third party or an agency to assist
Seebutrevised
Social Security in establishing rights to Social Security benefits and/or coverage; 2. To comply with Federal laws requiring the release of
Privacy Act
information from Social Security records (e.g., to the Government Accountability Office, General Services Administration, National Archives
Statement
Records Administration, and the Department of Veterans
Affairs); below.
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 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 agencies 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 Systems of Records Notices entitled, Claims Folder System, 60-0089, and
Supplemental Security Income Record, and Veterans Benefits, 60-0103. The notices, additional information regarding this form, and
information regarding our system and programs, are available on-line 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 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
1-800-772-1213 (TTY 1-800-325-0778) for the address. 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-L707 (08-2010) EF (08-2010)

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 to determine eligibility of benefits for Social Security
or Supplemental Security Income applicants.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination
regarding eligibility for benefits. However, we may use it for the administration and integrity of
our programs. We may also disclose the 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 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 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 our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
We also may use the information you give us in computer matching programs. Matching
programs compare our records with records kept by other Federal, State and 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.
A complete list of routine uses of the information you provided us is available in our Systems of
Records Notices entitled, Claims Folder System, 60-0089 and Supplemental Security Income
Record, and Special Veterans Benefits, 60-0103. Additional information about these and other
system of records notices and our programs are available online at www.socialsecurity.gov or at
your local Social Security office.