Form 86-5 (11-2018) UF
Discontinue Prior Editions Page 5 of 5
SOCIAL SECURITY ADMINISTRATION : : (OMB No. 0980-0066
Application for a Social Security Card
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4 [FULLNAME AT BIRTH First Fat Maas Nome ast
IF OTHER THAN ABOVE
[OTHER NAMES USED
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PLACE OF Office DATE x
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(Oo Not Abbreviatay City Siafe orForsign County FCT_| [BIRTH] __ MM/OD/YYYY
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