Request for Deceased Individual's Social Security Record

Form SSA-711 Internet Request
OMB No. 0960-0665
Paperwork Reduction Act

For information on how to complete this form, follow the form instructions.

Photocopy of Original Application for a Social Security Card (SS-5)

Computer Extract of Social Security Card Application

Certification is required, adds $10.00 to fee

We will not disclose information about any person in our records unless: 1) the number holder has provided written consent or we have acceptable proof of his or her death; or 2) the number holder is at least 100 years old and we have acceptable proof of his or her death; or 3) the number holder is more than 120 years old.

In addition, we do not release the parents’ names unless: 1) we have the parents’ written consent or acceptable proof of death for the parents; or 2) the number holder is at least 100 years old and we have acceptable proof of his or her death; or 3) the number holder is more than 120 years old.

Acceptable proofs of death include:

• a copy of a public record of death; or
• a statement of death from a funeral director; or
• a statement of death by the attending physician or the superintendent, physician, or intern of the institution where the person died; or
• a copy of the coroner’s report of death or the verdict of the coroner’s jury; or
• a copy of an official report of death or finding of death made by an agency or department of the U.S. which is authorized or required to make such a report or finding in the administration of any law in the U.S.; or
• an obituary with sufficient identifying information.

Name of individual at birth

*First	Middle	*Last

Name(s) of individual (if other than above/other name(s) used)

* Social Security Number

Date of birth

* Month	* Day	* Year
January February March April May June July August September October November December	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Gender

Male       Female

Parent/Mother's name at birth

First	Middle	Last

Parent/Mother's married name(s) (if any)

 

Parent/Father's name at birth

First	Middle	Last

Name

* First	Middle	* Last

Address

* Street Address 1

Street Address 2

* City	* State	* Zip
	AA AE AK AL AP AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN LA KS KY MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY	-

Telephone

Fax

E-mail