Date: ____________________

Social Security Administration
OEO FOIA Workgroup
300 N. Green Street
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  _____________________________

I understand the fee for this service is $27.00 when the Social Security Number is provided And $29.00 when it is not.  Included is my check for $ _________________  made out to the Social Security Administration to cover any administrative costs required by this request.:

Sincerely,
Name  (SIGN)   ______________________________
Name  (PRINT)  ______________________________
Address  (PRINT) ___________________________________
(City, State & Zip Code) ___________________________________

My Daytime Phone Number  (            ) ______ - __________________ 

WRITE A LARGE "FREEDOM OF INFORMATION REQUEST' ON THE ENVELOPE