Date:____________________

Social Security Administration
OEO FOIA Workgroup
6100 Wabash Ave
P.O. Box 33022
Baltimore, Maryland  21290-3022.

RE:  Freedom of Information Request

Dear Freedom of Information Officer,

I am writing this request under the Freedom of Information Act, 5 US.C. Section 552.

I hereby request PHOTOCOPIES of the Social Security File (including the SS-5 Application for Social Security Number) for the following individual:

NAME USED AT TIME OF DEATH
(PRINT)

First _______________________________

Middle:  ________________________

Last:  ___________________________SEX - Male ____ Female ____

SOCIAL SECURITY NO._____________________________

DATE OF BIRTH - mo day yr _____________________________

DATE OF DEATH - mo day yr _____________________________

FULL NAME OF FATHER  _____________________________

FULL MAIDEN NAME OF MOTHER   _____________________________