Form SSA-L106 Letter to Custodian of Birth Records

SOCIAL SECURITY ADMINISTRATION

LETTER TO CUSTODIAN OF SCHOOL RECORDS

Form Approved
OMB No. 0960-0693

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

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Form SSA-L106 -F3 (11-2010)
Destroy Prior Editions

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
Other

DO NOT SEND CASH

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Form SSA-L106 -F3 (11-2010)

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

PRIVACY ACT STATEMENT
Collection and Use of Personal Information

See Revised Privacy Act
Statement Attached

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 that person's
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 are available on-line at www.socialsecurity.gov or at your 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 only comments relating to our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD
21235-6401.

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Form SSA-L106 -F3 (11-2010)