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

Form SSA-711 (11-2018)
Discontinue Prior Editions
Social Security Administration

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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.

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 $21.00.
If SSN of deceased individual is not provided, the fee is $21.00.
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 $20.00.
If SSN of deceased individual is not provided, the fee is $20.00.
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.

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Form SSA-711 (11-2018)

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. Request for photocopy of Original Application for Social Security Card (SS-5).
Enter, $21.00, if SSN of deceased individual is provided

A. $

0. 00

Enter $21.00, if SSN of deceased individual is not provided

B. $

0. 00

Enter, $20.00, if SSN of deceased individual is provided

C. $

0. 00

Enter, $20.00, if SSN of deceased individual is not provided

D. $

0. 00

E. $

0. 00

F. $

0. 00

2. Request for Computer extract of Social Security Number Application.

3. If Certification is required, enter an additional $10.00
Add the amounts from Lines A through E and enter TOTAL on Line 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.” DO NOT SEND CASH. DO NOT SEND SELF-ADDRESSED
STAMPED ENVELOPE.
4. DECEASED INDIVIDUAL’S INFORMATION (COMPLETE AS MUCH INFORMATION AS POSSIBLE)
Name of Individual at birth (first, middle, last name)
Name(s) of Individual (if other than above/other name(s) used)

Check Sex
M

Social Security Number

Date of birth (mo, day, yr)

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)
Street Address
Telephone Number
7. Forward Request to:

Date
City, State, and ZIP Code

Fax Number

SSA OEIO DEBS FOIA
PO BOX 33022
Baltimore, MD 21290-3022

E-Mail Address
8. Forward Express Mail to:

SSA OEIO DEBS FOIA
6100 Wabash Ave.
Baltimore, MD 21215

F

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Form SSA-711 (11-2018)

PRIVACY ACT STATEMENT
Collection and Use of Personal Information
The Freedom of Information Act (FOIA) (5 U.S.C. § 552) and our regulations at 20 CFR 402.130 allows us
to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part
of the information may prevent us from accurately responding to your FOIA request.
We will us the information to verify the subject individual is deceased, access the correct Social Security
record, and process your request. We may also share your information for the following purposes, called
routine uses:
See Revised Privacy Act Statement Attached
• To student volunteers, individuals working under a personal services contract, and other workers
who technically do not have the status of Federal employees, when they are performing work for
the Social Security Administration (SSA), as authorized by law, and they need access to personally
identifiable information in SSA records to perform their agency assigned functions; and
• To National Archives and Records Administration, Office of Government Information Services
(OGIS), to the extent necessary to fulfill its responsibilities in 5 U.S.C. 552(h) to review
administrative agency policies, procedures and compliance with the FOIA, and to facilitate OGIS'
offering of mediation services to resolve disputes between persons making FOIA requests and
administrative agencies.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records to establish or verify a person's eligibility for Federal benefit programs and for repayment
of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0340,
entitled FOIA and Privacy Act Record Request and Appeal System, as published in the Federal Register
(FR) on July 13, 2016, at 81 FR 45352. Additional information, and a full listing of all SORNs, is available on
our website at https://www.ssa.gov/privacy.

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 (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.

SSA will insert the following revised Privacy Act and PRA Statements into the
form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information
The Freedom of Information Act (FOIA) (5 U.S.C. § 552) and our regulations at 20 CFR
402.130 allow us to collect this information. Furnishing us this information is voluntary.
However, failing to provide all or part of the information may prevent us from accurately
responding to your FOIA request.
We will use the information you provide to verify that the subject individual is deceased, access
the correct Social Security record and process your request. We may also share your information
for the following purposes, called routine uses:
•

To the National Archives and Records Administration (NARA), Office of Government
Information Services (OGIS), to the extent necessary to fulfill its responsibilities in 5
U.S.C. 552(h) to review administrative agency policies, procedures and compliance with
the FOIA, and to facilitate OGIS’ offering of mediation services to resolve disputes
between persons making FOIA requests and administrative agencies.

•

To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA
in the efficient administration of its programs. We will disclose information under this
routine use only in situations in which SSA may enter into a contractual or similar
agreement with a third party to assist in accomplishing an agency function relating to this
system of records.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0340, entitled Freedom of Information Act (FOIA) and Privacy Act Record Request
and Appeal System, as published in the Federal Register (FR) on July 13, 2016, at 81 FR 45352.
Additional information and a full listing of all our SORNs is available on our website at
www.ssa.gov/privacy.
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 regarding this burden estimate
or any other aspect of this collection, including suggestions for reducing this burden to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401.