Form SSA-1010 Request to Reproduce, Reprint, or Distribute SSA Forms,

Form Approved
OMB No. 0960-NEW

SOCIAL SECURITY ADMINISTRATION

Request to Reproduce, Reprint, or Distribute SSA Forms, Applications, or other Publications
Name:

Address:

Phone Number:

(
Company Name:

)

Phone Number:

Company Address:

(

)

Internet Address:
1. What are you requesting to print or publish?
Forms

Applications

Publications

Other

2. SSA Form, Application or Publication Numbers:

3. SSA Form, Application or Publication Names:

4. Will you sell the SSA Forms, Applications or Publications?

Yes

No

If you answered "YES" to this question, you must tell your client that the item is availabe FOR FREE from
SSA. Explain how you will do this.

5. How will you keep the SSA Forms, Applications or Publications current?

I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying
statements or forms, and it is true and correct to the best of my knowledge. I understand that anyone who
knowingly gives a false or misleading statement about a material fact in this information, or causes someone else
to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

SIGNATURE
SIGNATURE (First Name, Middle Initial, Last Name)
SIGN
HERE

PRINT NAME AND TITLE

Form SSA-1010 (5-2004) Destroy Prior Editions

DATE (Month, day, year)

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 8 minutes to read the instructions, gather the facts, and answer the questions. 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-1010 (08-2007) Destroy Prior Editions

2