RM 10225: Special Requests - SSN
TN 4 (10-09)
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:
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Each SS-5 is accompanied by a signed SSA-3288, along with a completed Certification of Records form.
If you require additional information, please do not hesitate to contact us. Thank you for your assistance in this matter.
Sincerely,
____________________________________
[typed name for authorized official]
[position]