Social Security Administration
FORM SS-5
Instructions

Application for a Social Security Number Card
(Original, Replacement, or Correction)

01-1987

INTRODUCTION

Enumeration is the process of applying for a Social Security number (SSN). To apply for an SSN, either the worker or the applicant/client must complete Form SS-5, Application for a Social Security Number Card. Ordinarily the applicant must sign Form SS-5. If the SSN is for a child under the legal guardianship or in custody of the state, the worker signs Form SS-5.

The following instructions are a summary of the enumeration procedures in the Welfare Enumeration Manual (WEM).

PURPOSE

To request an original or replacement SSN for applicants or clients of HHSC programs only.

SSN violations are a felony under federal law and are subject to a fine of not more than $5000 or imprisonment for not more than five years, or both.

PROCEDURE

When to Prepare

AFDC

AFDC/Food Stamps/Income Assistance Medical Programs

The worker or the applicant/client completes Form SS-5 for each applicant/client who does not have an SSN or for whom the number is unknown. The worker reads to the person or has the person read page 4 of Form SS-5. Page 4 explains

Note: Section A-1322 explains when the worker must refer applicants/clients to SSA for enumeration.

Adult Medical Assistance Only (MAO)

Applicants/clients are required to furnish HHSC an SSN as a condition of eligibility in the Supplemental Security Income-related MAO program. The adult MAO program, however, does not have a formal enumeration process. The Medicaid eligibility worker may help the individual obtain an SSN by furnishing the applicant/client a Form SS-5. The form includes an explanation of the Privacy Act of 1974 and the purpose and use of SSN information. The worker may also provide assistance in completing Form SS-5, if necessary. It is the responsibility of the MAO applicant/client to return Form SS-5 to SSA and to provide SSA with documentation of age, identity, citizenship, or legal alien status needed to obtain an SSN.

The only time a Medicaid eligibility worker completes Form SS-5 is if an applicant/client is 65 years old or older and does not have an SSN or a Social Security claim number (SSCN) for Medicare purposes, and is unwilling or unable to apply for Medicare on his own. In this situation, the worker must complete Form SS-5 and Form SSA-4040, Application for Supplemental Medical Insurance, to enroll the applicant/client in Part B of Medicare.

Foster Care

If the application is for AFDC foster care, the worker completes and signs Form SS-5 for each child who does not have an SSN or for whom the number is unknown.

The worker annotates "child in custody of the state" in Item 14.

See WEM 00305.145 for other special instructions.

Note: Section A-1322 of the Income Assistance Handbook explains when the worker must refer applicants/clients to SSA for enumeration.

Transmittal

The worker

Social Security Administration
Enumeration Branch
38 Courtright
Wilkes-Barre, PA 18701

The bottom left-hand corner of the envelope must be marked "WELFARE ENUMERATION."

Form Retention

The worker keeps a carbon or photocopy of the completed Form SS-5 in the case record until he receives Form H1000-B with the client's SSN. Note: The worker or office may maintain a log of all Forms SS-5 sent to SSA instead of copies.

Form Order Instructions

Order supplies of Form SS-5 from Business Management Division. Small emergency supplies may also be requested from local SSA offices.

Form Rejection Problems

If an applicant completes Form SS-5 incorrectly, SSA central office staff returns the form to the SSA district office. Regional directors for income assistance services and SSA district office managers are responsible for establishing procedures to see that these Forms SS-5 are returned to the worker for correction.

DETAILED INSTRUCTIONS

Complete Items 1 through 14 using black or dark blue ink. Print all information except the signature. Do not make any entry in the side margins.

Following are the 14 items and their location in the Welfare Enumeration Manual (WEM):

Item 1* — Name — WEM 00305.025 - 00305.035

Item 2* — Mailing Address — WEM 00305.040

Item 3* — Citizenship — WEM 00305.045

Item 4   — Sex — WEM 00305.050

Item 5   — Race/Ethnic Description — WEM 00305.055

Item 6   — Date of Birth — WEM 00305.060 - 00305.065

Item 7   — Present Age — WEM 00305.070

Item 8* — Place of Birth — WEM 00305.075

Item 9* — Parents' Names — WEM 00305.080 - 00305.085

Item 10 — Previous Applications — WEM 00305.090

Item 11 — Today's Date — WEM 00305.095

Item 12 — Telephone Number — WEM 00305.100

Item 13 — Signature — WEM 00305.105

Item 14 — Relationship — WEM 00305.110

*These items and the Evidence ID Code are the minimum information for processing Form SS-5.

ANNOTATIONS ON FORM SS-5

DATES

Three dates appear on Form SS-5. They are as follows:

AGE, IDENTITY, AND CITIZENSHIP OR LEGAL ALIEN STATUS

Ensure that the applicant for the SSN is the person he claims to be. Examine a combination of documents to establish the applicant's age, identity, and citizenship or legal alien status; do not use only one document.

Use the following documents to establish age and citizenship:

  1. Original or certified copy of the birth certificate issued by the custodian of the record,
  2. Notification of birth registration,
  3. Church birth or baptismal records, which were recorded near the time of birth, or
  4. Hospital birth certificate. (Certificates issued by the City of Faith Hospital, Tulsa, OK are not acceptable for enumeration purposes.)

If using a U.S. birth certificate as evidence, record

If using a church record, record the name and location of the church.

If the above records are not available, use other documents at least one year old. Examples are school records, census records, or other documents showing date of birth or age.

To establish legal alien status, see WEM 00310.145 and 00310.150. Show in the IDN block of Form SS-5 any alien registration numbers appearing on INS documents.

Identity can usually be established through such items as a driver's license, voter's registration card, school or employment ID, credit card with signature, library card, or any other document showing signature, photograph, or description.

For a child under 7 years old, a birth certificate alone is not sufficient evidence to establish identity unless no other evidence of identity exists. If no other evidence can be obtained for a child under 7 years old, indicate it on Form SS-5 in the IDN block.

When a person applying on behalf of another submits Form SS-5 in person, he must show evidence of his own identity as well as evidence of the age, identity, and U.S. citizenship or legal alien status of the person for whom he is applying. This usually occurs when a parent applies on behalf of a child.

Following the instructions in WEM 00301.055 and 00310.010, write the types of evidence reviewed in the IDN block of Form SS-5. Code "C" is the only acceptable entry in the IDN block. Then sign your name; enter your title and the date.

Additional sources of evidence are listed in WEM 00310.170.

IN PERSON INTERVIEW

If the applicant is age 18 or older and has never had an SSN before, conduct an in-person interview according to WEM 00310.015. Annotate the ITV block of Form SS-5.

WELFARE IDENTIFICATION NUMBER

The welfare identification number is the number used to notify the state via the welfare enumeration tape of the SSN that SSA assigns the client. Enter the welfare ID in the NPN block of Form SS-5.

The welfare ID in Texas is

  1. 45Ø - plus the nine-digit client number and the four-digit employee number; or
  2. 45Ø - plus the Notice of Application number (alpha "A" plus eight numerics) and the four-digit employee number; or
  3. 45Ø - plus the case number and the four-digit employee number.

Note: Always separate the state BENDEX code of 45Ø from the rest of the number by a dash (-). Also, write a numerical zero with a slash (Ø) to distinguish it from a letter "O."

Example: 45Ø - A12345678

Mail Form SS-5 to SSA, Wilkes-Barre, Pa. once the welfare ID can be entered in the NPN block of Form SS-5. All other information must be complete.

LOCAL SSA OFFICE CODE

Enter the three-digit numerical or alpha-numeric code to identify the local SSA office for the applicant's mailing address in the DOC block. A list of codes is at the end of these instructions.

LIST OF LOCAL SOCIAL SECURITY OFFICES

CITY LOCAL SSA
OFFICE CODE
CITY LOCAL SSA
OFFICE CODE
Abilene 829 Galveston 828
Alice 874 Georgetown E45
Amarillo 820 Greenville 845
Angleton A72 Harlingen 875
Austin 813 Houston (Southwest) 816
Beaumont 818 Houston (Downtown) D64
Big Spring 832 Houston (Northeast) 856
Brenham B48 Houston (Northwest) 855
Brownsville 824 Houston (Southeast) 857
Brownwood 842 Kerrville A75
Bryan 836 Laredo 840
Cleburne B47 Longview 835
Conroe A74 Lubbock 827
Corpus Christi 825 Lufkin 833
Corsicana 843 McAllen 841
Dallas (North) 814 McKinney A76
Dallas (Fair Park) 851 Marshall B50
Dallas (South Oak Cliff) 853 Midland A04
Dallas (West) 854 Mt. Pleasant I22
Del Rio I15 Nacogdoches B44
Denton A73 Odessa 834
Eagle Pass 844 Palestine 846
El Paso 817 Pampa 847
El Paso (Downtown) E24 Paris 831
Fort Worth 821 Pasadena 850
Fort Worth (South) E35 -

 continue

CITY LOCAL SSA
OFFICE CODE
- -
Plainview 848
Pleasant Grove E64
Port Arthur 830
San Angelo 822
San Antonio 815
San Antonio (South) 880
San Antonio (West) 852
San Marcos E44
Seguin B51
Sherman 837
Temple 838
Texarkana 757
Tyler 819
Vernon 849
Victoria 839
Waco 826
Waxahachie D20
Wichita Falls 823
Clovis, New Mexico
   P.O. Box 1419
   88101
862