Date and Place of Birth

If you were born outside the United States or its territories:

• Name of your birth country at the time of your birth (it may have a different name now)
• Permanent Resident Card number (if you are not a U.S citizen)

Medicaid Number

Current Heath Insurance

• Employment start and end dates for the current employer (of you or your spouse) who provides your health insurance coverage through a Group Health Plan 
• Start and end dates for the Group Health Insurance provided by you (or your spouse’s) current employer

Marriage and Divorce

• Name of current spouse 
• Name of prior spouse (if the marriage lasted more than 10 years or ended in death)
• Spouse(s) date of birth and SSN (optional)
• Beginning and ending dates of marriage(s)
• Place of marriage(s) (city, state or country, if married outside the U.S.)

U.S. Military Service

• Type of duty and branch
• Service period dates

Employer Details for Current Year and Prior 2 Years (not self-employment)

• View your Social Security Statement online at www.socialsecurity.gov/myaccount
• Employer name
• Employment start and end dates

Self-Employment Details for Current Year and Prior 2 Years

• View your Social Security Statement online at www.socialsecurity.gov/myaccount 
• Business type
• Total net income

Direct Deposit - Domestic bank (USA)

• Account type and number
• Bank routing number