SSA-L106 Letter to Custodian of Birth Records

Form SSA-L106-F3 (08-2017)
Destroy Prior Editions
Social Security Administration

Page 1 of 3
OMB No: 0960-0693
LETTER TO CUSTODIAN OF SCHOOL RECORDS

Claim Number:
Date:
PART 1 - TO BE COMPLETED BY REQUESTER
Name of Record Custodian:
Address of Record Custodian:

Sir/Madam:
I need to establish my date of birth to become entitled to Social Security benefits. I am requesting verification of my age
according to records that may be available at your school. I am providing the following information to help in searching
your records.
Name as Registered in School:

Nickname:

Date of Birth (Month, Day, Year):
Place of Birth (City, County, and State):
Name(s) of Parent(s) or Guardian(s) (First, Full Middle, Last):

We are adding an extra space here for Parents Names

Schools Attended (In same city or school district)
(1) Name of School (If unable to remember, give location):

Grade(s) Attended: Date(s) Attended:

Residence at Time of Attendance:

Remarks:

Schools Attended (In same city or school district)
(2) Name of School (If unable to remember, give location):

Residence at Time of Attendance:

Remarks:

Grade(s) Attended: Date(s) Attended:

Form SSA-L106-F3 (08-2017)

Page 2 of 3
LETTER TO CUSTODIAN OF SCHOOL RECORDS

Schools Attended (In same city or school district)
(3) Name of School (If unable to remember, give location):

Grade(s) Attended: Date(s) Attended:

Residence at Time of Attendance:

Remarks:

Signature

Street Address

Print Full Name

City and State

Phone Numbers with Area Code

Zip Code

Relationship to Person Whose Record is Being Requested
PART 2 - NOTARIZATION OF REQUESTER'S SIGNATURE (If Required)
Notary Public should use the space below for notarization and placement of seal.

PART 3 - PAYMENT INFORMATION
Enclosed is $

in the form of:
Personal Check
Certified Check
Money Order
No Fee Required
Other

DO NOT SEND CASH

Form SSA-L106-F3 (08-2017)

Page 3 of 3

LETTER TO CUSTODIAN OF SCHOOL RECORDS
PART 4 – CERTIFICATION BY CUSTODIAN OF SCHOOL RECORDS
The record is unavailable.
I certify the information below based on school records in my custody.
Name of School:
Address of School:
Name as Shown on School Records
Record:
Name(s) of Parent(s) or Guardian(s):
Age or Date of Birth as Shown on School Records:

If Date of Birth is not available, provide age as shown on school records
Records (Month, Day, Year):
Date of School Record

Place of Birth:
Remarks:
Signature and Title of Custodian of School Records:

Date:

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Signature
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ParentsCustodian
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Records:
Name of School or Agency Having Custody of Record:
Address (Street, City, State, Zip Code):

PRIVACY ACT STATEMENT
Collection and Use of Personal Information

Sections 205(a) and 1631of the Social Security Act, as amended, allow us to collect this information. Furnishing us this
information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely
decision on any claim filed. We will use the information to determine your eligibility for benefits, and may use the
information for the administration of our programs. We may also share your information for the following purposes, called
routine uses:

See Revised Privacy Act Statement Attached

1. To contractors and other Federal agencies, as necessary, for the purpose of assisting SSA in the efficient
administration of its programs. We will disclose information under this routine use only in situations in which SSA may
enter into a contractual or similar agreement with a third party to assist in accomplishing an agency function relating to this
system of records; and
2.To applicants or claimants, prospective applicants or claimants (other than the data subject), their authorized
representatives or representative payees to the extent necessary to pursue Social Security claims, and to representative
payees, when the information pertains to individuals for whom they serve as representative payees, for the purpose of
assisting the Social Security Administration in administering its representative payment responsibilities under the Act and
assisting the representative payees in performing their duties as payees, including receiving and accounting for benefits
for individuals for whom they serve as payees.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example,
where authorized, we may use and disclose this information in computer matching programs, in which our records are
compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of
incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN) 60-0089, entitled Claims
Folders Systems, 60-0090, entitled Master Beneficiary Record, and 60-0058, entitled Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information and a full listing of all our SORNs are available on
our website at www.socialsecurity.gov/foia/bluebook.
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 only comments relating to our time estimate above
to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.