SSA-L706 Letter to Custodian of Birth Records

Form SSA-L706 (03-2020) UF
Page 1 of 3
OMB No. 0960-0693

Discontinue Prior Editions
Social Security Administration

LETTER TO CUSTODIAN OF BIRTH RECORDS
SSN
Claim Number:
Date:
Custodian of Record: Please complete, sign, and date part 5 of this form, include your seal if you have one, and return
the form to requester/SSA.
PART 1 - TO BE COMPLETED BY REQUESTER

To Whom
Sir/Madam:

It May Concern:

the Social Security Administration (Check One) need(s) to establish a date of birth for SSA purposes. I request a
The

I/
certified

copy/

certification/

verification (Check One) of your record showing the date of birth based on:

The information below; or

The document attached.

Full Name at Birth:

Sex:

Date of Birth (MM/DD/YYYY): Place of Birth (City, County, and State):

Parent's or Mother's Maiden Name (First, Full Middle, Last):

Parent's or Father's Name (First, Full Middle, Last):

I authorize the disclosure of the requested information to the Social Security Administration.
Signature

Address

Print Full Name

Relationship to Above Person (e.g., Self, Authorized Applicant)

Phone Number with Area Code

PART 2 - NOTARIZATION OF REQUESTER'S SIGNATURE (If Required)
Notary Public should use the space below for notarization and placement of seal.

Form SSA-L706 (03-2020) UF
Page 2 of 3
LETTER TO CUSTODIAN OF BIRTH RECORDS
PART 3 - PAYMENT INFORMATION
Enclosed is $

in the form of:
Personal Check

Certified Check

Money Order

Credit Card (Type, Number, Expiration Date)
No Fee Required

Other

DO NOT SEND CASH
PART 4 - COMPLETED BY SSA OFFICIAL TO INDICATE RETURN ADDRESS/TO VERIFY REQUESTER'S IDENTITY
Signature

Social Security Office Name

Print Name and Title

Office Address

Office Telephone Number with Area Code/Extension

Verification of Requester's Identity (If Required)
I verified the requester's identity. The requester submitted the following as evidence of his/her identity:
PART 5 - TO BE COMPLETED BY RECORDS CUSTODIAN OR OFFICIAL
Choose option A, B, or C.
A.

Certified Birth Record Attached

B.

Certification/Verification of Birth Record
I verify the information on the document submitted.
I certify the information provided below.

Name as Shown on the Record

Date of Birth Or Age (If Date of Birth is not available, then Age)

If age has been provided in the above block, indicate age as of which birthday.
Type of Birth or Religious Record

Date of the Record

Place of Birth:

Parent's Full Name

Remarks:

Parent's Full Name

Last

Next

Nearest

Not Given

Form SSA-L706 (03-2020) UF
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LETTER TO CUSTODIAN OF BIRTH RECORDS
C.

Negative Certification/Verification
I searched for a

birth/

religious (Check One) record for the person named in Part 1 and found no record for

this person
him/her for the year(s).
D.

Signature and Seal
Yes (If Yes, affix seal)
No

Please sign and date, indicate your title, and provide address. Return to requester or SSA, as indicated on page 1.
Signature

Address (Street, City, State, ZIP Code):

Title

Date:

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a) and 1631 of the Social Security Act, as amended, 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 making an accurate and
timely decision on benefit eligibility.
We will use the information you provide to make a determination of eligibility to receive, or the right to continue receiving, Social
Security benefits or Supplemental Security Income (SSI) payments. We may also share your information for the following
purposes, called routine uses:
• To Federal, State, and local entities to assist them with administering income maintenance and health maintenance
programs, when a Federal statue authorizes them to use the Social Security Number *SSN);
• To third party contacts in situations where the party to be contacted has, or is expected to have, information relating to the
individual's capability to manage his/her affairs or his/her eligibility for or entitlement to benefits under the Social Security
program; and,
• To third party contacts that may have information relevant to the Social Security Administration's establishment or verification
of information provided by representative payees or payee applicants.
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 Notices (SORN) 60-0058, entitled Master Files
of SSN Holders and SSN Applications, as published in the Federal Register (FR) on December 29,2010, at 75 FR
82121;60-0089, entitled Claims Folders System, as published in the FR on April 1, 2003, at 68 FR 15784; and 60-0090, entitled
Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826. Additional information, and a full listing of
all of our SORNs, is available on our website at www.ssa.gov/privacy.

See Revised Privacy Act and
PRA Statements 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 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.