SOCIAL SECURITY ADMINISTRATION
         Facsimile Transmittal Sheet
         
            
               
                  
                  
               
               
                  
                  
                     
                     | TO: Central Records | FROM: | 
                  
                     
                     | COMPANY: CT Department of Corrections | DATE: | 
                  
                     
                     | FAX NUMBER: (860) 292-3453 | TOTAL NO. OF PAGES INCLUDING COVER: COVER ONLY | 
               
            
          
         PHONE NUMBER:
         (860) 292-3486
         RE:
         Prisoner Information
         NOTES/COMMENTS:
         Please send information regarding all confinements and convictions from ______________
            to the present for:
         
         Name:___________________________________________________________________
         Date of Birth:_____________________________________________________________
         Social Security Number:____________________________________________________
         Inmate Number:__________________________________________________________
         INFORMATION NEEDED:
         Dates of Confinement:
         Dates of Conviction:
         (or official date of parole revocation)
         
         Types of Offense(s) (Felony or Misdemeanor):
         (for convictions prior to 04/01/00)
         Length of Sentence:
         Date of Release, if any:
         Type of Release (Parole, Adult Probation, Community Release, etc.):