Form SSA-1535-U3 Application for Search of Census Records for Proof of Ag

ONLY SHOW INFORMATION FOR CENSUS YEARS TO BE SEARCHED
CENSUS
DATE

NUMBER AND STREET
(Very important)

CITY, TOWN, TOWNSHIP
(Precinct, beat, etc.)

NAME OF PERSON WITH WHOM
LIVING (Head of household)

COUNTY AND STATE

RELATIONSHIP

APRIL 15, 12A.
1910
12B.

APRIL 1,
1930

12C.

APRIL 1,
1940

12D.

1. CLAIM NUMBER

3. FIRST NAME

MIDDLE NAME

4. DATE OF BIRTH (If unknown, estimate)

MAIDEN NAME (if any)

CASE NO.

PRESENT LAST NAME

5. PLACE OF BIRTH (City, County, State)

7. FULL NAME OF FATHER (Stepfather, guardian, etc.)

NICKNAME
6. SEX
9. ETHNICITY
HISPANIC OR LATINO
NOT HISPANIC OR LATINO

8. FULL MAIDEN NAME OF MOTHER (Stepmother, etc.)

ONLY SHOW INFORMATION CONCERNING MARRIAGES
PRIOR TO DATE OF LAST CENSUS YEAR TO BE SEARCHED
10. FULL NAME OF HUSBAND OR WIFE

10A. YR. MARRIED
(Approximate)

11. FULL NAME OF HUSBAND OR WIFE

11A. YR. MARRIED
(Approximate)

12. RACE (SELECT ONE OR MORE)
AMERICAN INDIAN OR ALASKA
NATIVE
ASIAN
BLACK OR AFRICAN AMERICAN
NATIVE HAWAIIAN OR OTHER
PACIFIC ISLANDER
WHITE

BUREAU OF THE CENSUS
P. O. BOX 1545
JEFFERSONVILLE, IN 47131
ATTN: AGE SEARCH UNIT

13. REMARKS

TO:

APPLICATION FOR SEARCH OF
CENSUS RECORDS FOR PROOF OF AGE
(For Social Security Purposes Only)

Form Approved
OMB No. 0960-0097

DO NOT
USE
THIS
SPACE

2. WAGE EARNER'S NAME

FORM SSA-1535-U3 (08-2009) EF (08-2009)
Destroy Prior Editions

I authorize the Bureau of the Census to send the record to the Social Security Administration to be used by that agency only for
purposes in connection with my entitlement to Social Security benefits. (ATTENTION is called to the possibility that the
information shown in the census record may not agree with that given in your application. The record must be copied exactly as it
appears.)
14. SIGNATURE OF APPLICANT (Do not print)
15. ADDRESS (Number and Street, City, State, ZIP Code)

If signed by mark (X), two witnesses must sign
below:
15A. SIGNATURE OF WITNESS
15B. SIGNATURE OF WITNESS

DISTRICT OFFICE ADDRESS (Number and Street, City, State, ZIP Code)

AUTHORIZATION OF PAYMENT FOR CENSUS SEARCH
Please furnish census information and bill SSA, pursuant to
agreement between Bureau of Census and SSA.
SIGNATURE (District manager or
authorized employee)

16. DATE

SSA COPY

DISTRICT OFFICE - DO NOT DETACH THIS STUB

JAN. 1,
1920

Privacy Act Statement
Collection and Use of Personal Information

See Revised Privacy Act Statement Attached

20 CFR 404.716 of the Social Security regulations authorizes us to collect this information. The information you provide will be forwarded
by the Social Security Administration to the Bureau of the Census for their use in searching their records for establishing your age.
The information you furnish on this form is voluntary. However, failure to provide the requested information could prevent an accurate or
timely decision on your claim for benefits.
We rarely use the information you supply for any purpose other than for determining 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 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.
Additional information regarding this form, routine uses of information, and our programs and systems, is available on-line at
www.socialsecurity.gov or at your local Social Security office.

See Revised PRA Statement 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 12 minutes to read the instructions, gather the facts, and answer the
questions. SEND OR BRING 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 (TTY 1-800-325-0778). 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.

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
Privacy Act Statement

Collection and Use of Personal Information
Social Security regulation 20 CFR 404.716 authorizes us to collect this information. We will
forward the information you provide to the Bureau of the Census for their use in searching their
records to verify your age.
The information you furnish on this form is voluntary. However, failure to provide the requested
information may prevent an accurate and timely decision on your entitlement to Social Security
benefits.
We rarely use the information you supply for any purpose other than for determining
reimbursements. 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 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 Notice
entitled, Claims Folders Systems, 60-0089. This notice, additional information regarding this
form, and information regarding our programs and systems, are available on-line at
http://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 20 minutes to read the instructions, gather
the facts, and answer the questions. SED OR BRIG THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security
office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800772-1213 (TTY 1-800-325-0778). 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