Form SSA-7050-F4 Request fo Social Security Earning Information

Form Approved
OMB No. 0960-0525

REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION
*Use This Form If You Need

1. Certified/Non-Certified Detailed Earnings Information
Includes periods of employment or self-employment and the
names and addresses of employers.
OR
2. Certified Yearly Totals of Earnings
Includes total earnings for each year but does not include
the names and addresses of employers.

DO NOT USE THIS FORM FOR:
Non-certified yearly totals of earnings
This service is free to the public.
These totals can be obtained by calling
1-800-772-1213 to receive Form SSA-7004,
Request for Earnings and Benefit Estimate
Statement.

PRIVACY ACT NOTICE: We are authorized to collect this information under section 205 of the Social Security Act, and
the Federal Records Act of 1950 (64 Stat. 583). It is needed so we can identify your records and prepare the statement you
request. You do not have to furnish the information, but failure to do so may prevent your request from being processed.
PAPERWORK REDUCTION ACT: This information collection meets the clearance requirements of 44 U.S.C. §3507, as
amended by Section 2 of the Paperwork Reduction Act of 1995. You are not required to answer these questions unless we
display a valid Office of Management and Budget control number. We estimate that it will take you about 11 minutes to
read the instructions, gather the necessary facts, and answer the questions.
INFORMATION ABOUT YOUR REQUEST
• How Do I Get This Information?
You need to complete the attached form to tell us
what information you want.
• Can I Get This Information For Someone Else?
Yes, if you have their written permission. For
more information, see page 3.
• Who Can Sign On Behalf Of The Individual?
The parent of a minor child, or the legal guardian
of an individual who has been declared legally
incompetent, may sign if he/she is acting on behalf
of the individual.
• Is There A Fee For This Information?
1. Certified/Non-Certified Detailed
Earnings Information
Yes, we usually charge a fee for detailed
information. In most cases, this information is
used for purposes NOT directly related to Social
Security such as for a private pension plan or
personal injury suit. The fee chart on page 3
gives the amount of the charge.
Sometimes, there is no charge for detailed
information. If you have reason to believe your
earnings are not correct (for example, you have
previously received earnings information from us

Form SSA-7050-F4 (1-2004)
Destroy prior editions

EF (1-2004)

and it does not agree with your records), we
will supply you with more detail for the period
in question. Occasionally, earnings amounts
are wrong because an employer did not
correctly report earnings or earnings are
credited to the wrong person. In situations like
these, we will send you detailed information, at
no charge, so we can correct your record.
Be sure to show the year(s) involved on the
request form and explain why you need the
information. If you do not tell us why you need
the information, we will charge a fee.
We will certify the detailed earnings
information for an additional fee of $15.00.
Certification is usually not necessary unless you
plan to use the information in court.
2. Certified Yearly Total of Earnings
Yes, there is a fee of $15 to certify yearly totals
of earnings. Cetification is usually not
necessary unless you plan to use the information
in court.
3. Method of Payment
Enclose a check or money order for the entire
fee required. Payment can also be made by
credit card. To do so, complete page 4 of this
form and return it with your request form.

REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION
1. From whose record do you need the earnings information?
Print the Name, Social Security Number (SSN), and date of birth below.
Name

Social Security
Number

Other Name(s) Used
(Include Maiden Name)

Date of Birth
(Mo/Day/Yr)

2. What kind of information do you need?
For the period(s)/year(s):

Detailed Earnings Information
(If you check this block, tell us below
why you need this information.)

Certified Total Earnings For Each Year.
For the year(s):
(Check this box only if you want the information
certified. Otherwise, call 1-800-772-1213 to
request Form SSA-7004, Request for Earnings
and Benefit Estimate Statement)
3. If you owe us a fee for this detailed earnings information, enter the amount due
using the chart on page 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Do you want us to certify the information?
If yes, enter $15.00

A. $

Yes

No

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.

ADD the amounts on lines A and B, and
enter the TOTAL amount . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . .

B. $
C. $

• You can pay by CREDIT CARD by completing and returning the form on page 4, or
• Send your CHECK or MONEY ORDER for the amount on line C with the request
and make check or money order payble to "Social Security Administration"
• DO NOT SEND CASH.
4. I am the individual to whom the record pertains (or a person who is authorized to sign on behalf of that
individual). I understand that any false representation to knowingly and willfully obtain information from
Social Security records is punishable by a fine of not more than $5,000 or one year in prison.
SIGN your name here
(Do not print) >

Date

Daytime Phone Number
(Area Code) (Telephone Number)

5. Tell us where you want the information sent. (Please print)
Name

Address

City, State & Zip Code
6. Mail Completed Form(s) To:
Social Security Administration
Division of Earnings Record Operations
P.O. Box 33003
Baltimore Maryland 21290-3003
Form SSA-7050-F4 (1-2004) EF (01-2004)

Exception: If using private contractor (e.g., FedEx) to mail form(s), use:
Social Security Administration
Division of Earnings Record Operations
300 N. Greene St.
Baltimore Maryland 21290-0300
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REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION
How Much Do I Have to Pay For Detailed Earnings?
1. Count the number of years for which you need detailed earnings information. Be sure to add in both the first and last year
requested. However, do not add in the current calendar year since this information is not yet available.
2. Use the chart below to determine the correct fee.
Number of Years Requested

Fee

Number of Years Requested

Fee

Number of Years Requested

Fee

1

$15.00

15

$43.75

28

$64.50

2

17.50

16

45.50

29

66.00

3

20.00

17

47.25

30

67.50

4

22.50

18

49.00

31

68.75

5

25.00

19

50.75

32

70.00

6

27.00

20

52.50

33

71.25

7

29.00

21

54.00

34

72.50

8

31.00

22

55.50

35

73.75

9

33.00

23

57.00

36

75.00

10

35.00

24

58.50

37

76.25

11

36.75

25

60.00

38

77.50

12

38.50

26

61.50

39

78.75

13

40.25

27

63.00

40

80.00

14

42.00
For Requests Over 40 Years, Please Add 1 Dollar for Each Additional Year.

• Whose Earnings Can Be Requested
1. Your Earnings

3. A Deceased Person's Earnings
You can request earnings information from the record
of a deceased person if you are the legal representative
of the estate, a survivor (that is, the spouse, parent,
child, divorced spouse of divorced parent), or an
individual with a material interest (example-financial)
who is an heir at law, next of kin, beneficiary under the
will or donee of property of the decedent.

You can request earnings information from your own
record by completing the attached form; we need your
handwritten signature. If you sign with an "X", your
mark must be witnessed by two disinterested persons
who must sign their name and address.
2. Someone Else's Earnings

Proof of death must be included with your request.
Proof of appointment as representative or proof of your
relationship to the deceased must also be included.

You can request earnings information from the record
of someone else if that person tells us in writing to give
the information to you. This writing or "authorization"
must be presented to us within 60 days of the date it
was signed by that person.

Form SSA-7050-F4 (1-2004) EF (01-2004)

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YOU CAN MAKE YOUR PAYMENT BY CREDIT CARD

As a convenience, we offer you the option to make your payment by credit card. However, regular credit card rules will apply.
You may also pay by check or money order.

Please fill in all the information below and return
this form along with your request to:

Exception:
If using private contractor (e.g., FedEx) to mail form(s), use:

Social Security Administration
Division of Earnings Record Operations
P.O. Box 33003
Baltimore Maryland 21290-3003

Social Security Administration
Division of Earnings Record Operations
300 N. Greene St.
Baltimore Maryland 21290-0300

Note: Please read Paperwork/Privacy Act Notice
CHECK ONE

Visa

American

MasterCard

Discover

Diners Card

Credit Card Holder's Name
(Enter the name from the credit card)

First Name, Middle Initial, Last Name

Number & Street

Credit Card Holder's Address

City, State, & Zip Code

Daytime Telephone Number
Area Code

Credit Card Number

Telephone Number

___________--____________--____________--__________

Credit Card Expiration Date

Month

Year

Amount Charged

Credit Card Holder's Signature
Authorization

DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY

Name

Date

Remittance Control #

PRIVACY ACT NOTICE
The Social Security Administration (SSA) has authority to collect the information requested on this form under section 205 of the
Social Security Act. Giving us this information is voluntary. You do not have to do it. We will need this information only if
you choose to make payment by credit card. You do not need to fill out this form if you choose another means of payment (for
example, by check or money order).
If you choose the credit card payment option, we will provide the information you give us to the banks handling your credit card
account and SSA's account. We may also provide this information to another person or government agency to comply with
federal laws requiring the release of information from our records. You can find these and other routine uses of information
provided to SSA listed in the Federal Register. If you want more information about this, you may call or write any Social
Security Office.
Form SSA-7050-F4 (1-2004) EF (1-2004)

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