Form SSA-1696

Form SSA-1696 (08-2020)
Section 1 - Claimant's Information
Social Security Number*
Full Name*

First NameMiddle InitialLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Alternate Phone Number (Optional)
Section 8 - Signatures
Signature

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Date

MonthDayYear
Date
Should be Empty: