Form SSA-704 Certification of Contents of Document(s) or Record(s)

FORM APPROVED
OMB No. 0960-0689

TOE 420

CERTIFICATION OF CONTENTS OF DOCUMENT(S) OR RECORD(S)

SOCIAL SECURITY ADMINISTRATION

SOCIAL SECURITY NUMBER

NAME OF NUMBER HOLDER

EXTRACT TRANSLATION OF (Specify)
Language Document

Every item in a block must be filled out with EXACT EXCERPTS from the document certified or the item must be marked "NS" or "Not shown." If the date on
which an entry was made in a family record is "not shown," indicate under "Remarks" any allegation as to when the document or record was established. Include
any other pertinent information shown on the document under "Remarks." Cross out all unused blocks, (e.g., if a certification is made only in block "A1," cross out
"A2," " B," "C," "D," and "E.")

A. AGE, RELATIONSHIP OR CITIZENSHIP OF:
1.

NAME OF PERSON AS SHOWN ON EVIDENCE

SEX

DATE OF BIRTH

MALE

PLACE OF BIRTH

FEMALE
NOT SHOWN
AGE

NOT
SHOWN

BIRTHDAY AGE SHOWN

LAST

NOT GIVEN

NEXT

DATE RECORDED (if religious record, show date of
ceremony)
NOT SHOWN

NEAREST

NAME OF FATHER

NOT SHOWN

NATURE OF EVIDENCE

AGE

NAME OF MOTHER

NOT SHOWN

AGE

CUSTODY OF DOCUMENT
APPLICANT
RECORD CUSTODIAN
OTHER (Relationship to Applicant)
DATE DOCUMENT ISSUED (If certifying from a
PUBLIC
DOCUMENT NO.
CUSTODIAN Bible, give date of publication or last copyright, and
complete part E)

NAME AND ADDRESS OF ISSUING AGENCY IF NOT A PUBLIC RECORD
(include ZIP Code)

2.

NAME OF PERSON AS SHOWN ON EVIDENCE

SEX

DATE OF BIRTH

MALE

PLACE OF BIRTH

FEMALE
NOT SHOWN
AGE

NOT
SHOWN

BIRTHDAY AGE SHOWN

LAST

NOT GIVEN

NEXT

DATE RECORDED (if religious record, show date of
ceremony)
NOT SHOWN

NEAREST

NAME OF FATHER

NOT SHOWN

NATURE OF EVIDENCE

AGE

NAME OF MOTHER

NOT SHOWN

AGE

CUSTODY OF DOCUMENT
APPLICANT
RECORD CUSTODIAN
OTHER (Relationship to Applicant)
DATE DOCUMENT ISSUED (If certifying from a
PUBLIC
DOCUMENT NO.
CUSTODIAN Bible, give date of publication or last copyright, and
complete part E)

NAME AND ADDRESS OF ISSUING AGENCY IF NOT A PUBLIC RECORD
(include ZIP Code)

B. MARRIAGE OF:
NAME OF HUSBAND AS SHOWN ON EVIDENCE

NAME OF WIFE AS SHOWN ON EVIDENCE

PREVIOUS MARRIAGES
(0, 1, 2, etc.)
NOT
SHOWN

DATE OF BIRTH

PREVIOUS MARRIAGES
(0, 1, 2, etc.)
NOT
SHOWN

DATE OF BIRTH

AGE

AGE

BIRTHDAY AGE SHOWN
LAST

NEAREST

NEXT

NOT GIVEN

BIRTHDAY AGE SHOWN
LAST

NEAREST

NEXT

NOT GIVEN

MARRIAGE CERTIFICATE PLACE OF MARRIAGE
BIBLE (complete part E)

NATURE OF EVIDENCE

CUSTODY OF DOCUMENT

RECORD
CUSTODIAN

APPLICANT

DATE OF MARRIAGE

OTHER (Relationship
to Applicant)

PUBLIC
DOCUMENT NO.
CUSTODIAN

NAME AND ADDRESS OF ISSUING AGENCY IF NOT A PUBLIC RECORD (include ZIP Code)

C. DEATH OF:
NAME OF DECEASED AS SHOWN ON EVIDENCE

CUSTODY OF DOCUMENT
RECORD
APPLICANT
CUSTODIAN

DATE OF DEATH

NATURE OF EVIDENCE

OTHER (Relationship
to Applicant)

PLACE OF DEATH

DEATH CERTIFICATE

DOCUMENT NO.
PUBLIC
CUSTODIAN

NAME AND ADDRESS OF ISSUING AGENCY IF NOT A PUBLIC RECORD (include ZIP Code)

FORM SSA-704-F3 (09-2005) EF (09-2005)

CAUSE OF DEATH

(OVER)

D. SERVICE IN U.S. ARMED FORCES OF:
NAME OF PERSON AS SHOWN ON EVIDENCE

RANK

DATE OF BIRTH OR AGE

BRANCH (Army, Navy, etc.)

DATE ENLISTED OR INDUCTED

MEANS OF ENTRY INTO
SERVICE

SERIAL NO.

CHARACTER OF DISCHARGE:
OTHER (Describe)

NATURE OF EVIDENCE

DATE ENTERED ACTIVE DUTY

INDUCTED

ORIGINAL DISCHARGE

DATE DISCHARGED OR RELEASED FROM ACTIVE DUTY

CALLED FROM INACTIVE DUTY

HONORABLE

DATE BIRTH OR AGE RECORDED

ENLISTED

RE-ENLISTED

COMMISSIONED

REASON AND AUTHORITY FOR SEPARATION

NOT SHOWN

PERSON SUBMITTING DOCUMENT, RELATIONSHIP TO APPLICANT, AND ADDRESS (include ZIP Code)

NAME AND ADDRESS OF ISSUING AGENCY IF NOT A PUBLIC RECORD (include ZIP Code)

APPLICANT

CUSTODIAN DATE DOCUMENT ISSUED

DOCUMENT NO.

E. EVALUATION OF FAMILY BIBLE OR SIMILAR FAMILY RECORD:
Claimant's allegation as to person who made the entry:
1. NAME

3. RELATIONSHIP TO CLAIMANT

2. ADDRESS (include ZIP Code)

4. DATE ENTRY MADE

Examination of record.
1.
2.
3.

Does entire entry appear to have been made by the same person at the same time?
Is record made in:
Ink
Pencil
Ballpoint Pen
Other
Describe the condition of the paper (yellow, brittle, etc.), and the condition of the book:

4.
5.
6.
7.

Is entry faded?
Yes
No
Does entry appear to be:
Old
Recent
Date Bible printed or published.
If photocopy cannot be submitted, answer the following:
a. Are entries arranged chronologically?
Yes
No (Explain in Remarks)
b. Name and date as shown in the entry immediately before and immediately after the entry for the claimant:

8.

a.

Entry before
Who has had custody of the record?

b.

Who made the entry?

F. REMARKS:

Yes

No (Explain in Remarks)

Entry after
c. When was the entry made?

d.

How does the claimant know this?

NOTE: - Do not use this form to abstract from any court order (e.g., divorce, annulment and adoption decrees, etc.) or to certify the
contents of any foreign (non-English) language document unless you are an authorized SSA translator.

G. AUTHENTICATION OF DOCUMENT(S) OR RECORD(S) DESCRIBED ABOVE.
CERTIFICATION: - I have personally examined the documents and records above and CERTIFY their contents in connection with an application
for benefits under Title II, Title XVI, and/or Title XVIII of the Social Security Act, as amended. Unless otherwise stated, all the entries herein are
exact excerpts from such documents or records. The entries are free from erasures, interlineation, or other alterations and the general
appearance of the documents or records satisfactorily establish their authenticity. The entries (in the case of original records) appear to have
been made at the time the record was purportedly established, and there is no reason to doubt the validity of the records or entries, unless
otherwise stated and explained under "Remarks."
SIGNATURE

DATE

OFFICIAL TITLE
CLAIMS
REPRESENTATIVE

SERVICE
REPRESENTATIVE

SENIOR CLAIMS
SPECIALIST

QUALITY ASSURANCE
SPECIALIST

FIELD
REPRESENTATIVE

DATA REVIEW
TECHNICIAN

CLAIMS DEVELOPMENT
CLERK

STATE RECORD
CUSTODIAN

FORM SSA-704-F3 (09-2005) EF (09-2005)

OTHER
(Specify)

Privacy Act Statement

See revised Privacy Act and Paperwork
Reduction Act Statements below.

The information requested on this form is authorized by the Social Security Act, Sections
205(a), 163a(e)(1)(A) and (B), and 1631(f), and Title 20 CFR 404.707. The information
provided will allow Social Security Administration to determine eligibility factors. This is
in situations where obtaining photography of an original or certified document is not
possible. You do not have to provide the information requested. However, the data you
provide will allow the Social Security Administration to determine eligibility factors of the
person who is applying for Social Security or SSI benefits. If you do not complete this
form, that person may not be entitled to benefits. The information you furnish may be
disclosed by SSA for the following purposes (1) to assist SSA in determining the right to
Social Security benefits for the applicant or another person; (2) to facilitate statistical
research and audit activities necessary to assure the integrity and improvement of
programs administered by SSA, and (3) to comply with laws and regulations requiring
the exchange of information between SSA and another 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 provide 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 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. 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-704-F3 (09-2005) EF (09-2005)

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 OR
BRING 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 1-800-772-1213 (TTY 1800-325-0778). 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.

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1631(e)(1), and 1631(f), of the Social Security Act, as amended, authorizes us
to collect this information. We will use the information you provide to make a decision on your
application for benefits.
Furnishing us this information is voluntary. However, failing to provide all or part of the
information could prevent us from making a timely decision on your application.
We rarely use the information you supply for any purpose other than for the reasons explained
above. However, 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 and improvement of Social Security programs (e.g., to the Bureau of Census and
to private entities under contract with us).
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 incorrect
payments or delinquent debts under these programs.
A complete list of routine uses of the information you gave us is available in our Privacy Act
System of Records Notices entitled, Claims Folder System, 60-0089 and Completed
Determination Record, 60-0050. Additional information about this and other systems of records
notices and our programs are available from our Internet website at www.socialsecurity.gov or at
your local Social Security Office.