Social Security Application

FORM NCI-5
TREASURY DEPARTMENT
INTERNAL REVENUE SERVICE
(Revised April 1939)

APPLICATION FOR SOCIAL SECURITY ACCOUNT NUMBER
REQUIRED UNDER CHAPTER 9, SUBCHAPTER 4, OF THE INTERNAL REVENUE SERVICE CODE
(FORMERLY TITLE VIII, SOCIAL SECURITY ACT)
READ INSTRUCTIONS ON BACK BEFORE FILLING IN FORM

284-18-8501

EACH ITEM SHOULD BE FILLED IN. IF THE INFORMATION CALLED FOR IN ANY ITEM IS NOT KNOWN, WRITE "UNKNOWN."

1

William

Crawford

Beeler Jr.

WORKER'S FIRST NAME

MIDDLE NAME (IF YOU HAVE NO MIDDLE NAME, DRAW A LINE)

LAST NAME

(MARRIED WOMAN - FOR MIDDLE NAME, GIVE LAST NAME BEFORE MARRIAGE; FOR LAST NAME, GIVE HUSBAND'S LAST NAME)

2

FULL NAME UNDER WHICH YOU WORK, IF DIFFERENT FROM NAME GIVEN INT ITEM 1

-

3

1011 Webster Ave. Hamilton Ohio

4

Mildred Irene Augustin

WORKER'S PRESENT HOME ADDRESS (STREET AND NUMBER) (CITY) (STATE)

MARRIED MAN - GIVE WIFE'S FULL NAME BEFORE MARRIAGE

5

West Side Federal S. & L.

6

201 Main Street Hamilton Ohio

BUSINESS NAME OF PRESENT EMPLOYER

BUSINESS ADDRESS OF PRESENT EMPLOYER (STREET AND NUMBER) (CITY) (STATE)

7

19

8

October 22, 1920

9

Hamilton Butler Ohio

AGE AT LAST BIRTHDAY

DATE OF BIRTH (MONTH) (DAY) (YEAR)
(SUBJECT TO LATER VERIFICATION)

PLACE OF BIRTH (CITY) (COUNTY) (STATE)

10

William Crawford Beeler, Sr.

11

Jessie Slayback

FATHER'S FULL NAME, REGARDLESS OF WHETHER LIVING OR DEAD

MOTHER'S FULL NAME BEFORE MARRIAGE, REGARDLESS OF WHETHER LIVING OR DEAD

12

SEX: MALE

X

FEMALE

-

13

COLOR OR RACE: WHITE

X

NEGRO

-

OTHER

-

(CHECK WHICH)

(CHECK WHICH)

(SPECIFY)

14

HAVE YOU FILLED OUT A CARD LIKE THIS BEFORE? YES

-

NO

X

-

-

CHECK WHICH AND IF ANSWER IS "YES" ENTER PLACE AND DATE OF ORIGINAL FILING AND REASONS FOR FILING AGAIN)

15

Nov. 27 1939

16

William Crawford Beeler Jr.

DATE SIGNED

APPLICANT'S (DO NOT PRINT) SIGNATURE (FIRST NAME) (MIDDLE NAME) (LAST NAME)

RETURN COMPLETED APPLICATION TO, OR SECURE INFORMATION ON HOW TO FILL OUT APPLICATION FROM, NEAREST SOCIAL SECURITY
BOARD FIELD OFFICE. THE ADDRESS CAN BE OBTAINED FROM LOCAL POST OFFICE.