"Social Security Number Record Change Request" - New Jersey

Social Security Number Record Change Request is a legal document that was released by the New Jersey Department of Education - a government authority operating within New Jersey.

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New Jersey State Department of Education
Office of Certification and Induction
SOCIAL SECURITY NUMBER RECORD CHANGE REQUEST
Please note that incomplete forms will be returned. Concerned with the proliferation of identity theft,
the department now requires submission of multiple forms of identification
A. Basic Information Please print your name as it appears on any documentation that you are required to submit
Last Name
First Name
Middle Name or Initial
Street Address
City
State
Zip
Social Security Number
Date of Birth: Month
Day
Year
Tracking Number
B. Status Failure to complete these items will result in rejection of this form.
Circle whichever applies
Have you ever had a certificate revoked or suspended in this or any state?
If yes, enclose a statement indicating the action taken and provide the pertinent details.
Yes
No
Circle whichever applies
Have you ever been convicted of a criminal offense in this or any other state
or any jurisdiction outside of the United States? If yes, enclose a statement
indicating the municipality where this occurred and provide the pertinent details.
Yes
No
C. Documentation Requirements: In this section, the applicant is required to submit no less than two types of identification in addition to a photocopy
of an individual’s social security card, which is mandatory. Clear and legible photocopies of these cards and papers should be attached to this form.
Once completed and notarized, the form and the attachments should be forwarded to: New Jersey State Department of Education, Office of Licensure
and Credentials, P.O. Box 500, Trenton, New Jersey, 08625-0500. Attention: Social Security Number Record Change Request
Submission of identification – Check boxes of those items for which you have attached copies.
Required Copy of Your Social Security Card -- A photocopy of the applicant’s social security card must be submitted as one of three types of
identification for the purpose of changing an individual’s social security number. For a replacement card please contact the Social Security
Administration at 1-800-772-1213 or go to
http://www.ssa.gov/ssnumber
and click on Replacement Card. The remaining two items may be selected
from the items listed below.
Also include copies of any two of the following items.
Certificate of Birth (Raised Seal Copy)
Valid New Jersey or Out-of-State Auto Operator License
United States Passport (current or expired within 3 years)
Adoption Papers
Certificate of Citizenship
Certificate of Naturalization
Valid United States Military Photo ID Card
Valid New Jersey Non-Driver Digital ID Card
I certify that all statements and information provided herein are true and accurate.
D. Applicant’s Signature (in ink)
Date
Sworn and subscribed to before me this ____________________day of _________________________, 20______
Notary Seal
Notary Signature
_____________________________________________________
Once completed, mail the form to: New Jersey State Department of Education
Office of Certification and Induction
P.O. Box 500
Trenton, New Jersey 08625-0500
Attention: Social Security Number Record Change Request
New Jersey State Department of Education
Office of Certification and Induction
SOCIAL SECURITY NUMBER RECORD CHANGE REQUEST
Please note that incomplete forms will be returned. Concerned with the proliferation of identity theft,
the department now requires submission of multiple forms of identification
A. Basic Information Please print your name as it appears on any documentation that you are required to submit
Last Name
First Name
Middle Name or Initial
Street Address
City
State
Zip
Social Security Number
Date of Birth: Month
Day
Year
Tracking Number
B. Status Failure to complete these items will result in rejection of this form.
Circle whichever applies
Have you ever had a certificate revoked or suspended in this or any state?
If yes, enclose a statement indicating the action taken and provide the pertinent details.
Yes
No
Circle whichever applies
Have you ever been convicted of a criminal offense in this or any other state
or any jurisdiction outside of the United States? If yes, enclose a statement
indicating the municipality where this occurred and provide the pertinent details.
Yes
No
C. Documentation Requirements: In this section, the applicant is required to submit no less than two types of identification in addition to a photocopy
of an individual’s social security card, which is mandatory. Clear and legible photocopies of these cards and papers should be attached to this form.
Once completed and notarized, the form and the attachments should be forwarded to: New Jersey State Department of Education, Office of Licensure
and Credentials, P.O. Box 500, Trenton, New Jersey, 08625-0500. Attention: Social Security Number Record Change Request
Submission of identification – Check boxes of those items for which you have attached copies.
Required Copy of Your Social Security Card -- A photocopy of the applicant’s social security card must be submitted as one of three types of
identification for the purpose of changing an individual’s social security number. For a replacement card please contact the Social Security
Administration at 1-800-772-1213 or go to
http://www.ssa.gov/ssnumber
and click on Replacement Card. The remaining two items may be selected
from the items listed below.
Also include copies of any two of the following items.
Certificate of Birth (Raised Seal Copy)
Valid New Jersey or Out-of-State Auto Operator License
United States Passport (current or expired within 3 years)
Adoption Papers
Certificate of Citizenship
Certificate of Naturalization
Valid United States Military Photo ID Card
Valid New Jersey Non-Driver Digital ID Card
I certify that all statements and information provided herein are true and accurate.
D. Applicant’s Signature (in ink)
Date
Sworn and subscribed to before me this ____________________day of _________________________, 20______
Notary Seal
Notary Signature
_____________________________________________________
Once completed, mail the form to: New Jersey State Department of Education
Office of Certification and Induction
P.O. Box 500
Trenton, New Jersey 08625-0500
Attention: Social Security Number Record Change Request