Campbell County Social Security Death Index

Social Security Application Form

 
Please fill out the form below and press submit. If you make an error,
simply use your backspace key or press the reset key at the bottom.

PLEASE NOTE: THIS FORM IS NOT TO BE USED TO REQUEST SOCIAL SECURITY CARDS. IT IS TO BE USED TO POST HISTORICAL AND GENEALOGICAL INFORMATION FROM SOCIAL SECURITY APPLICATIONS OF DECEASED INDIVIDUALS.

REQUESTS FOR SOCIAL SECURITY CARDS OR OTHER INFORMATION WILL NOT BE ACKNOWLEDGED OR POSTED.

 INSTRUCTIONS:
  • Information should be as complete as possible. If any fields are blank on certificate, enter "(left blank)" on the form. If a question on this form is not even asked on the certificate, just skip the question on the form.
  • Please enter all information directly from the actual application except where indicated otherwise. Add explanations or information contrary to (or in addition to) the application, or to further explain something on the application, in the "Comments" section at bottom of the form.
  • Please double check your email address.
Full Name of Applicant: 
**(as it appears on the application)
Present Mailing Address: 
Enter Full Name at Birth if different from above: 
Age at Last Birthday: 

Date of Birth: 
Place of Birth: 
Father's Full Name: 
Mother's Full Maiden Name: 
Sex: 
Race: 
Business Name or Address of Employer: 
Date Signed:  19
Your Name: 
Your Email: 
Your relationship to the applicant: 

Comments or Additional Information:
(Please add any discrepancies here.)


 


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