Form SSA-702 Statement Regarding Date of Birth and Citizenship

SOCIAL SECURITY ADMINISTRATION

Form Approved
OMB No. 0960-0016
(Do not write in this space)

TOE 420

STATEMENT REGARDING DATE OF BIRTH AND CITIZENSHIP
This report is authorized by section 205(a) of the Social Security Act, as
amended (42 U.S.C. 405(a)). While your response is voluntary, your
cooperation is needed to help us make a determination about the date of
birth and/or citizenship of the person named below.

All items on this form requiring an answer must be answered or marked "Unknown."

/
(Name of wage earner, self-employed person, or SSI applicant)

/

(Social Security Number)

, understand that the information I give will be used with

I,
(Name of person making this statement)

an application for benefits payable under the Social Security Act.
1. Give full name of person about whom this statement is made:

3. When was he or she born? (Month, day, year)

2. How many years have you known this
person?

4. Where was he or she born? (City or county--State
or foreign country)

5. How did you learn about this person's date of birth? (Tell fully how you know when this person was born.)

6. How are you related to this person? (If not related, write "None.")

7. When and Where
Were YOU
Born?

MONTH-DAY-YEAR

CITY OR COUNTY

STATE OR FOREIGN COUNTRY

I know that anyone who makes a false statement or representation of a material fact in an application or for use in determining a right to
payment under the Social Security Act commits a crime punishable under Federal and/or State law by fine, imprisonment or both. I
affirm that all information I have given in this document is true.

SIGNATURE OF PERSON MAKING STATEMENT
Signature (First name, middle initial, last name) (Write in ink)

Date (Month, day, year)
Telephone Number (Include area code)

Mailing Address (Number and street, Apt. No., P.O. Box, or Rural Route)
City and State

ZIP Code

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two witnesses to the
signing who know the person making the statement must sign below, giving their full addresses.
1. Signature of Witness

Address (Number and Street, City, State and ZIP Code)

Form SSA-702 (10-2011) EF (10-2011)
Destroy Prior Editions

2. Signature of Witness

Address (Number and Street, City, State and ZIP Code)

Privacy Act Statement
Collection and Use of Personal Information
See Revised Privacy Act Statement

Sections 205(a) and 1631(e)(1)(A) and (B) of the Social Security Act, as amended, [42 U.S.C. 405(a)] and
[42 U.S.C. 1383(e)(1)(A) and (B)] authorize us to collect this information. We will use the information you provide to help
us establish age and or citizenship.
The information you provide on this form is voluntary. However, failure to provide the requested information may prevent
an accurate and timely decision on any claim filed, or could result in the loss of benefits. We rarely use the information
you provide on this form for any purpose other than for the reasons explained above. 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, including but not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to Social Security benefits and or coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g., to the Government
Accountability Office, General Services Administration, National Archives Records Administration, and the
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 our programs (e.g., to the U.S. Census Bureau 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. 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.
Additional information regarding this form, routine uses of information, and our systems and programs, is available on-line
at www.socialsecurity.gov or at any Social Security office.

Paperwork Reduction Act (PRA) Statement
See Revised PRA
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 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.

Form SSA-702 (10-2011) EF (10-2011)

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

Sections 205(a), 1614(a)(1)(B), and 1631(e)(1)(A) and (B) of the Social Security Act, as
amended, allow us to collect this information. We will use the information you provide to help
us establish age and or citizenship of the applicant for one or more Social Security benefit(s).
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent us from making an accurate and timely decision on any claim filed, or
could result in the loss of benefits.
We rarely use the information you supply for any purpose other than what we state above,
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 Notices 60-0090, entitled Claims Folders
Systems and 60-0103, entitled Supplemental Security Income Record and Special Veterans
Benefits. Additional information about these and other system of records notices and our
programs are available from our Internet website 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.

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.