Free Social Security Number Referral, HCF 16022 - Wisconsin

STATE OF WISCONSIN DEPARTMENTS OF HEALTH SERVICES & WORKFORCE DEVELOPMENT Divisions of Heath Care Access and Accountability & Workforce Solutions F-16022 (07/08)

SSN
Case Number Worker ID Other ID as required Date

SOCIAL SECURITY NUMBER REFERRAL
Case Name Agency Name State and County Code

INSTRUCTIONS
In order to determine eligibility for Department of Health and Family Services and Department of Workforce Development program benefits, the persons listed below must apply for a Social Security Number. To apply you need: · This form; and · Proof of age, identity, and citizenship or non-citizen status for each person; and · Form SS-5, "Application for a Social Security Card," for each person. See second page of this form for examples of proofs of age, identity, and citizenship or non-citizen status. Persons age 18 or older who have never had a Social Security Number before must apply for a card in person at a Social Security Administration office. Non-citizens, whose immigration documents should not be mailed, must apply in person. Others may apply in person or by mail. If you wish to apply by mail, send the required forms and the required proof to the Social Security Administration office at: Address of Social Security Office (Street, City, State, Zip Code)

After you have applied, the Social Security Administration worker will complete the bottom section of this form and return the form to you or mail it to your local agency. If the form is returned to you, give it to your worker as proof that you have applied for a Social Security Number(s).

THE FOLLOWING PEOPLE MUST APPLY FOR A SOCIAL SECURITY NUMBER

SOCIAL SECURITY ADMINISTRATION CERTIFICATION
Please assist the above-named person(s) in applying for a Social Security Number. Sign this form and return it to the applicant or mail it to the county agency at: Address of county agency (Street, City, State, Zip Code)

I certify that on

, the above named person(s) applied for a Social Security Number. MM/DD/CCYY SIGNATURE - Social Security Administration Designee Title Date Signed

RESET FORM

Social Security Number Card Referral F-16022 (07/08)

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An applicant for a Social Security Number must provide proof of age, identity, and US Citizenship, or lawful non-citizen status. All documents submitted as evidence must either be originals or copies certified by the issuing agency. The Social Security Administration (SSA) will not accept uncertified or notorized photocopies. If you have any questions about proper evidence, or need help in obtaining documents, please call or visit your nearest SSA office.

SECTION I - UNITED STATES CITIZEN, BORN IN THE USA - APPLYING FOR ORIGINAL NUMBER
You must submit one document from List A and one from List B List A - Evidence of age and citizenship One of the following records established before your 5th birthday: · Public birth certificate (this is the preferred document; you should submit it if possible);

· ·

Religious record showing age or date of birth (to establish citizenship, it must have been recorded within 3 months of birth); or Hospital record of birth.

If your birth was never recorded or the public record no longer exists, submit documents from List B for evidence of age and citizenship. At least one document must show your name, age or date of birth, and your place of birth. It should at least be one year old. List B - Evidence of identity A public or hospital record is not considered evidence of identity. An identity document should contain enough information to identify you. Some items SSA looks at on the document are name, age, address, signature, physical description, and picture. Examples of such records are: · Identity card

· · · · · · · · · · · · ·

Driver's license Adoption record Insurance policy Youth organization record Any other document providing identifying date sufficient to establish proper identity school record Medical record Work badge or building pass Military record Religious record (if not submitted as evidence of age) Marriage or divorce record United States passport United States citizen Identification card Court order for a name change

SECTION II - UNITED STATES CITIZEN, BORN OUTSIDE THE USA - APPLYING FOR ORIGINAL NUMBER
If you were born outside the United States of America but are a U. S. citizen you should submit either: 1. U. S. consular report of birth (FS-240 or FS-545) and evidence of your identity (see section I, List B); or 2. Your foreign birth certificate (if not available, another document showing age or date of birth) and one of the following:

· · ·

Citizenship Certificate U.S. Passport Certificate of Naturalization

SECTION III - NON-CITIZEN APPLYING FOR ORIGINAL NUMBER
If you are a non-citizen living in or visiting the U. S., you should submit your foreign birth certificate (if available) or passport and one or more of the following:

· ·

Alien Registration Receipt Card I-151 or I-551 U.S. Immigration Form I-94 (and I-201D, if applicable), I-568 (and I-144, if applicable), I-181A, I-185, I-186, or I-210

SECTION IV - ANY APPLICANT REQUESTING A REPLACEMENT (DUPLICATE OR CORRECTION)
You must present evidence at least of your identity, such as one or more of the documents listed in section I, List B or in Sections II or III. In addition, if you are foreign born (or U. S. born, but no longer a U. S. citizen) you must submit evidence of your current U. S. citizenship or lawful non-citizen status. After SSA examines your documents, you may be asked for additional evidence of your age or U. S. citizenship or lawful non-citizen status.