Social Security Application

FORM ???  
TREASURY DEPARTMENT  
INTERNAL REVENUE SERVICE  
(Revised 7-48) 

APPLICATION FOR SOCIAL SECURITY ACCOUNT NUMBER 
REQUIRED UNDER THE FEDERAL INSURANCE CONTRIBUTIONS ACT  
READ INSTRUCTIONS ON BACK BEFORE FILLING IN FORM 

273-28-0759 
DO NOT WRITE IN THE ABOVE SPACE 

FILL IN EACH ITEM. PRINT IN BLACK OR BLUE INK OR USE TYPEWRITER FOR ALL SPACES EXCEPT SIGNATURE. IF THE INFORMATION CALLED FOR IN ANY ITEM IS NOT KNOWN, WRITE "UNKNOWN." 

1

PRINT NAME YOU GAVE YOUR PRESENT   
EMPLOYER OR IF UNEMPLOYED, THE   
NAME YOU WILL USE WHEN EMPLOYED

FIRST NAME   MIDDLE NAME   LAST NAME 
Chester E. Hollenbaugh

2

MAILING ADDRESS 

3

PRINT FULL NAME GIVEN YOU AT BIRTH

4

AGE ON LAST BIRTHDAY 

5

DATE OF BIRTH (MONTH) (DAY) (YEAR)  

6

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

7

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

8

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

9

SEX

MALE

FEMALE

10

COLOR OR RACE

WHITE

BLACK

OTHER

11

-

YES

NO

?

X

-

X

-

-

-

-

-

12

BUSINESS NAME OF EMPLOYER. IF UNEMPLOYED, WRITE "UNEMPLOYED." 

IF ANSWER IS "YES" PRINT THE   
STATE IN WHICH YOU FIRST   
APPLIED AND WHEN

STATE

DATE

-

-

EMPLOYER'S ADDRESS (NO. AND STREET) 

ALSO PRINT YOUR ACCOUNT   
NUMBER IF YOU KNOW IT

ACCOUNT NUMBER

-

13

TODAY'S DATE

14

WRITE YOUR NAME

RETURN COMPLETED APPLICATION TO NEAREST SOCIAL SECURITY ADMINISTRATION FIELD OFFICE.