Social Security Verification Form

Date________________

Name of Student – PRINT or type name exactly as printed on Social Security CARD
______________________________________________________
Student ID #: ___________________________________________
School Name: ___________________________________________
The last 4 digits on card: ___________________

I, _______________________________, (print name) verify that the student listed above

has a social security card which I have seen. The card does not state that additional
documentation is needed for work, and therefore indicates that this student is eligible to
work.

__________________________________, Signature (person verifying card)

I am:
_____Internship Teacher Champion
_____ Academy Teacher
_____ Guidance Counselor
_____ School Administrator
_____ M-DCPS District Sta

DO NOT COPY OR SCAN SOCIAL SECURITY CARD

Rev. 04-09-20 Page 26