Certification of Prison Records by Prison Officials

CERTIFICATION OF PRISON RECORDS

DATE: _______________________
NAME: _______________________
INMATE ID #: _________________
SOCIAL SECURITY #:____________
Social Security Administration
(address)
(location)

Attached, please find a completed Form SS-5 (Application for Social Security Number) requesting a
replacement Social Security number card for the above named individual.
I, the undersigned, certify that I have reviewed the above inmate's official prison record and that the
identifying information shown below is accurate according to that record.
NAME

_________________________________

DATE OF BIRTH

_________________________________

PLACE OF BIRTH

_________________________________

MOTHER'S MAIDEN NAME _________________________________
FATHER'S NAME

_________________________________

If you have any further questions, please contact me between the hours of ______ to ______. My
telephone number is _____________.

_____________________________
[signature]
[typed name for authorized official]
[prison name, city]

OMB Control Number 0960-0688