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

Form Approved

Social Security Administration OMB No. xxxx-xxxx

REQUEST FOR PROOF(S) FROM CUSTODIAN OF RECORDS

Date: _________________________________ Unit Number: _________________________

Number Holder: __________________________

TO: Custodian of Records

_________________________________

ADDRESS

_________________________________

_________________________________

►Please furnish a certified copy of your record or a Letter of No Record for the following event(s):

 Death

 Marriage

 Divorce

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):

 The Social Security office OR  My address below.

(Please Print) (Please Print)

Social Security Administration ________________________

Attention: NAME

_________________________ ________________________ ADDRESS ADDRESS

_________________________ ________________________

_________________________ ________________________

 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 (00-2007) Destroy Prior Editions Page 1

►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 (first, middle, last) _______________________________________

Date of Birth (month, day, year) ___________________________________________

Place of Birth __________________________________________________________

Name of Bride (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 marriage record.

► If unable to locate record, please indicate years searched and sign. _____________________________

Divorce Record

Name of Husband (first, middle, last) __________________________________________

Date of Birth _____________________________________________________________

Name of Wife (first, middle, maiden) __________________________________________

Date of Birth_____________________________________________________________

Date of Divorce (month, day, year) __________________________________________

If date unknown, years to be searched _________________________________________

County and state where divorce occurred ____________________________________________

►If unable to locate record, please indicate years searched and sign. _____________________________

Privacy Act – The Privacy Act requires us to notify you that we are authorized to collect this information by section 205(a) of the Social Security Act. You do not have to provide the information requested. The data you provide, however, will allow the Social Security Administration to determine the eligibility for benefits of a person who is applying for Social Security or Supplemental Security Income benefits. If you do not complete this form, that person may not be entitled to benefits. We do not disclose the information you provide to any person or other government agency. We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it. Explanations about these and other reasons why information you give us may be used or given out are available in Social Security offices. If you want to learn more about this, contact any 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 THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Form SSA-L707 (00-2007) Destroy Prior Editions Page 2