Seguro Social En Los Eeuu

Complying with one full calendar month September

Enter no later

October

Remain in the US for the whole month

November

Leave on or after the first day of the month

Personally Identifiable Information (PII) Name Social Security Number Date of Birth Official State issued Driver's License or Identification Number Alien Registration Number Government Passport Number Employer or Taxpayer Identification Number Home Address Medical Information Personally Identifiable Information (PII) is information that can be used, alone or with other information, to identify a specific individual. Any information that can be used to search for or identify individuals, or can be used to access their files, is personally identifiable information

PRIVACY ACT WAIVER I hereby request the staff of the Federal Benefits Unit – Mexico City - to provide information about my Social Security benefits and/or identifying information to any and all agencies. ______________________________ Complete Name (please print) Date of birth

Social Security Number Place of birth

Father’s name:_____________________________________________ Mother’s maiden name:______________________________________ __________________________ Signature

_____________________ Date

I am the individual to whom the information/record applies or that person's parent (if a minor) or legal guardian. I declare under penalty of perjury that I have examined all the information on this form and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both. (02/07)