Social Security Card Replacement Application

Person on record general information displayed on the card

* Required field

First Name *

Middle Name (optional)

Last Name *

Have you a different name at Birth? *

Yes

Have you got any other name? *

Yes

First name at Birth *

Middle Name at Birth (Optional)

Last Name at Birth *

List any other names

Person on record birth information

Country of birth *

City of birth *

Date of birth

Day *

Month *

Year *

Gender *

Male

Female

Your relationship with the person on record

Self

Mother

Father

Person on records parents information

Parent's SSNs are not required to obtain a replacement Social Security card. Be sure to input mother's maiden name
(last name at birth).

Mother's Maiden Name

Do you know your Mother's Social Security Number?

Yes

Father's Last Name

Do you know your Father's Social Security Number?

Yes

Person on record citizenship information

Are you U.S. Citizen? *

Yes

Are you allowed to work legally? *

Yes

Do you have a legal status in the U.S.? *

Yes

Contact information

Phone Number *

Email *

Reason of application

Email confirmation *

User agreement

By checking this box, I agree to submit the information provided to this website, and I authorize www.ssnsimple.com to use my information to fill all necessary documents in order to prepare my application materials. I understand that www.ssnsimple.com is a private document preparation service and that I am hiring them to prepare my social security card application documents. I understand there is a service fee charged by www.ssnsimple.com. I understand I will have to provide an original identification document to the Social Security Office to prove my identity. I understand that I may receive newsletters from www.ssnsimple.com and its direct partners. By submitting the form above, I agree to these terms and the terms and conditions of this website. *

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