0422 Form 15116 (PDF)

Official source: IRS Forms, Instructions & Publications (https://www.irs.gov/pub/irs-pdf/f15116.pdf), retrieved 2026-10-03. U.S. Government work (17 U.S.C. § 105).

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(April 2022)

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Department of the Treasury - Internal Revenue Service

Full name at birth Date of birth

Any other name used on your returns

Mother's full name at birth

Father's full name

Have you ever applied for or had a Social Security number

Yes No

If you answered "yes" to the question above, complete the following information about where and when you received your Social Security number

Name of state Date received Enter the Social Security number you received

Your current mailing address

Street

City State ZIP code

Your telephone number

Work Home

Convenient hours for us to call you

Catalog Number 69810S www.irs.gov Form 15116 (4-2022)