Evidence Submitted

This is the field where you must document the types of evidence submitted. You must document all required evidence for the individual in #1 and if someone other than the individual in #1 signs the SS-5, his/her identity must be documented. See #16 if SS-5 is completed by a Department employee for a Department ward.

Record the type of document and the issuing agency, registration, field, or volume/page number, location of any hospital, etc.

Example:

NE B/C #B-102 99-9999

St. Lukes Clinic Immunization Record

Mother's NE D/L #A-99999999

(Mother applying on behalf of her child)

Signature