Social Security Administration
STATEMENT OF CLAIMANT OR OTHER PERSON
__________________________________________________________________
Your Name
__________________________________________________________________
Name of Person Making Statement (If Different)
Relation to Wage Earner
Understanding that this statement is for the use of the Social Security
Administration, I hereby certify that the answers to questions and the information
provided in this statement is true to the best of my knowledge and belief.
1. Have you even been in the United States (including Guam, the Northern
Mariana Islands, and American Samoa) before?
2. Have you ever worked in the United States (including Guam, the Northern
Mariana Islands, and American Samoa) before?
3. Have you ever been claimed as a spouse or a dependent on a U.S. tax
return?
Signature ________________________________
Date ____________________