"Social Security Number Request Application Form" - Florida

This Florida-specific "Social Security Number Request Application Form" is a document released by the Florida Department of Juvenile Justice.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Download "Social Security Number Request Application Form" - Florida

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Florida Department of Juvenile Justice
2737 Centerview Drive / Tallahassee, FL 32399-3100 / 850-921-5900
Social Security Number Request Application
Requestor’s Name: _________________________________________________________________
Commercial Entity:_________________________________________________________________
Nature of Business:_________________________________________________________________
Federal ID Number:_________________ Social Security Number(s) Requested:________________
Mailing Address:__________________________________________________________________
City____________________ County____________________ State______ Zip Code____________
Primary Phone # (_____) _______-________
Alternate Phone # (_____) ______-_______
In the space provided, state the business purpose for which the social security number(s) of DJJ and/or
contract provider employees is necessary and how this information will be used in the normal course of
business. __________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in are true.
Date
_____/______/______
_______________________________________________________
Signature of Requestor
Printed Name
:_______________________________________
STATE OF FLORIDA
COUNTY OF
__________________
Sworn or affirmed and signed before me on
day of
20
by
________
__________________
_______
____________________________________.
_____________________________________________
____________________________________________________________
NOTARY PUBLIC
Print, type, or stamp commissioned name of notary or deputy clerk.
Personally known
_______
Produced identification
_______
Type of identification produced _____________________________________
FOR INTERNAL USE ONLY
Submitted By: ______________________________
DJJ Branch
General Counsel Review: □ Yes
or
□ No
Information Released: □ Yes
or
□ No
Attorney: __________________________________ Date: ______/______/______
A copy of this form shall be submitted to the Office of Legislative Affairs, 2737 Centerview Drive, Suite 3200, Tallahassee, FL
32399- 3100.
A copy of this form shall be submitted to the Office of Legislative Affairs, 2737 Centerview Drive, Suite 310,
Tallahassee, FL 32399-3100.
Florida Department of Juvenile Justice
2737 Centerview Drive / Tallahassee, FL 32399-3100 / 850-921-5900
Social Security Number Request Application
Requestor’s Name: _________________________________________________________________
Commercial Entity:_________________________________________________________________
Nature of Business:_________________________________________________________________
Federal ID Number:_________________ Social Security Number(s) Requested:________________
Mailing Address:__________________________________________________________________
City____________________ County____________________ State______ Zip Code____________
Primary Phone # (_____) _______-________
Alternate Phone # (_____) ______-_______
In the space provided, state the business purpose for which the social security number(s) of DJJ and/or
contract provider employees is necessary and how this information will be used in the normal course of
business. __________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in are true.
Date
_____/______/______
_______________________________________________________
Signature of Requestor
Printed Name
:_______________________________________
STATE OF FLORIDA
COUNTY OF
__________________
Sworn or affirmed and signed before me on
day of
20
by
________
__________________
_______
____________________________________.
_____________________________________________
____________________________________________________________
NOTARY PUBLIC
Print, type, or stamp commissioned name of notary or deputy clerk.
Personally known
_______
Produced identification
_______
Type of identification produced _____________________________________
FOR INTERNAL USE ONLY
Submitted By: ______________________________
DJJ Branch
General Counsel Review: □ Yes
or
□ No
Information Released: □ Yes
or
□ No
Attorney: __________________________________ Date: ______/______/______
A copy of this form shall be submitted to the Office of Legislative Affairs, 2737 Centerview Drive, Suite 3200, Tallahassee, FL
32399- 3100.
A copy of this form shall be submitted to the Office of Legislative Affairs, 2737 Centerview Drive, Suite 310,
Tallahassee, FL 32399-3100.
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