TN 4 (10-09)

RM 10225.155 Exhibits: Replacement SSN Cards for Prison Inmates

A. Exhibit 1 Letter for authorized signatures

                                                                                      [Institution Letterhead]

                                                                                      [date]

Social Security Administration

[Local office address]

Dear [name]

Pursuant to procedures contained in the Memorandum of Understanding between our agencies, I hereby authorize the following [Name of facility] staff to submit inmate applications for replacement SSN cards to your office and certify the identifying information found in inmates’ official prison records:

                              [Signature]___________________________________

                              [Print name. position]

                              [Signature]____________________________________

                              [Print name, position]

                              [Signature]____________________________________

                              [Print name, position]

                              [Signature]____________________________________

                              [Print name, position]

Please contact me at [telephone number] if you have any questions.

                                                                 Sincerely,

                                                                 ___________________________

                                                                 [Signature]

                                                                 ___________________________

                                                                 [Printed Name]

                                                                 ___________________________

                                                                 [Warden or Similar Official]

B. Exhibit 2 Certification of prison records

                       [Institution Letterhead]

CERTIFICATION OF PRISON RECORDS

                                                                 DATE: __________________________

                                                                  NAME: ____________________

                                                                 INMATE ID #: ___________________

                                                                 SOCIAL SECURITY #: ____________________

Social Security Administration

(address)

(locations

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

C. Exhibit 3 Cover letter

                                                  [Institution Letterhead]

                                                        Day/Month/Year

Social Security Administration

Attn: [Appropriate Official Name & Title]

Address

City, State ZIP Code

Dear [Name]:

Pursuant to procedures contained in the Memorandum of Understanding between our agencies, we are enclosing recently completed SS-5 applications for replacement Social Security Number cards for the following inmates:

                 _________