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pdfONLY 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
JAN. 1,
1920
12B.
APRIL 1, 12C.
1930
APRIL 1, 12D.
1940
1. CLAIM NUMBER
2. WAGE EARNER'S NAME
3. FIRST NAME
MIDDLE NAME
4. DATE OF BIRTH (If unknown, estimate)
DO NOT
USE
THIS
SPACE
MAIDEN NAME (if any)
CASE NO.
PRESENT LAST NAME
5. PLACE OF BIRTH (City, County, State)
7. FULL NAME OF FATHER (Stepfather, guardian, etc.)
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
Form Approved
OMB No. 0960-0097
NICKNAME
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
TO:
APPLICATION FOR SEARCH OF
CENSUS RECORDS FOR PROOF OF AGE
(For Social Security Purposes Only)
13. REMARKS
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)
FORM SSA-1535-U3 (06-2012) EF (06-2012)
Destroy Prior Editions
16A. DATE
CENSUS BUREAU
See Revised Privacy Act Statement Attached
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.
2.
of
3.
4.
To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;
To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department
Veterans’ Affairs);
To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and,
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 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. 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 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.
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
JAN. 1,
1920
12B.
APRIL 1, 12C.
1930
APRIL 1, 12D.
1940
1. CLAIM NUMBER
2. WAGE EARNER'S NAME
3. FIRST NAME
MIDDLE NAME
4. DATE OF BIRTH (If unknown, estimate)
DO NOT
USE
THIS
SPACE
MAIDEN NAME (if any)
CASE NO.
PRESENT LAST NAME
5. PLACE OF BIRTH (City, County, State)
7. FULL NAME OF FATHER (Stepfather, guardian, etc.)
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
Form Approved
OMB No. 0960-0097
NICKNAME
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
TO:
APPLICATION FOR SEARCH OF
CENSUS RECORDS FOR PROOF OF AGE
(For Social Security Purposes Only)
13. REMARKS
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)
FORM SSA-1535-U3 (06-2012) EF (06-2012)
Destroy Prior Editions
16A. DATE
CENSUS BUREAU
See Revised Privacy Act Statement Attached
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.
2.
of
3.
4.
To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;
To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department
Veterans’ Affairs);
To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and,
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 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. 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 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.
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
JAN. 1,
1920
12B.
APRIL 1, 12C.
1930
APRIL 1, 12D.
1940
1. CLAIM NUMBER
2. WAGE EARNER'S NAME
3. FIRST NAME
MIDDLE NAME
4. DATE OF BIRTH (If unknown, estimate)
DO NOT
USE
THIS
SPACE
MAIDEN NAME (if any)
CASE NO.
PRESENT LAST NAME
5. PLACE OF BIRTH (City, County, State)
7. FULL NAME OF FATHER (Stepfather, guardian, etc.)
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
Form Approved
OMB No. 0960-0097
NICKNAME
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
TO:
APPLICATION FOR SEARCH OF
CENSUS RECORDS FOR PROOF OF AGE
(For Social Security Purposes Only)
13. REMARKS
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)
FORM SSA-1535-U3 (06-2012) EF (06-2012)
Destroy Prior Editions
16A. DATE
SSA COPY
See Revised Privacy Act Statement Attached
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.
2.
of
3.
4.
To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or coverage;
To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government Accountability Office and Department
Veterans’ Affairs);
To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and,
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 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. 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 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 Statement into the form at its next scheduled
reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Section 205(a), of the Social Security Act, as amended, authorizes us to collect this information.
We will forward the information you provide to the Bureau of the Census for their use in
searching Census records to verify your age.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than for determining benefits
eligibility. However, we may use the information for the administration of our programs
including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0089, entitled, Claims Folders
System. Additional information about this and other system of records notices and our programs
is available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs 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.
| File Type | application/pdf |
| File Title | Printing L:\BRIAN'~1\REVISI~1\SSA-1535\S1535.FRP |
| Author | 838994 |
| File Modified | 2014-08-20 |
| File Created | 2014-08-20 |