[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