Form SSA-7004 Request for Social Security Statement (paper version)

Form Approved
OMB No. 0960-0446

SP

Request for Social Security Statement
Please check this box if you want to get your
Statement in Spanish instead of English.
Please print or type your answers. When you have
completed the form, fold it and mail it to us. If you
prefer to send your request using the Internet, go to
www.socialsecurity.gov.
1. Name shown on your Social Security card:
First Name

Middle Initial

For items 6 and 8, show only earnings covered by
Social Security. Do NOT include wages from state,
local or federal government employment that are
NOT covered by Social Security or that are covered
ONLY by Medicare.
6. Show your actual earnings (wages and/or net
self-employment income) for last year and your
estimated earnings for this year.
A. Last year’s actual earnings: (Dollars Only)

$

,

.0

0

B. This year’s estimated earnings: (Dollars Only)

$

Last Name Only

,

.0

0

2. Your Social Security number as shown on your
card:

7. Show the age at which you plan to stop working:

3. Your date of birth (Mo.-Day-Yr.)

8. Below, show the average yearly amount (not your
total future lifetime earnings) that you think you
will earn between now and when you plan to stop
working. Include performance or scheduled pay
increases or bonuses, but not cost-of-living increases.

4. Other Social Security numbers you have used:

5. Your Sex:

Male

Female

(Show only one age)

If you expect to earn significantly more or less in
the future due to promotions, job changes, parttime work or an absence from the work force,
enter the amount that most closely reflects your
future average yearly earnings.
If you don’t expect any significant changes,
show the same amount you are earning now
(the amount in 6B).
Future average yearly earnings: (Dollars Only)

$
Form SSA-7004-SM (06-2008) EF (06-2008)
10-2006 edition may be used

,

Printed on recycled paper

.

0 0

9. Do you want us to send the Statement:
• To you? Enter your name and mailing
address.
• To someone else (your accountant, pension
plan, etc.)? Enter your name with “c/o” and
the name and address of that person or
organization.
“C/O” or Street Address (Include Apt. No., P.O. Box, Rural Route)
Street Address
Street Address (If Foreign Address, enter City, Province, Postal Code)
U.S. City, State, ZIP code (If Foreign Address, enter Name of Country only)

NOTICE:
I am asking for information about my own
Social Security record or the record of a person
I am authorized to represent. I declare under
penalty of perjury that I have examined all the
information on this form, and on any
accompanying statements or forms, and it is
true and correct to the best of my knowledge.
I authorize you to use a contractor to send the
Social Security Statement to the person and
address in item 9.

Please sign your name (Do Not Print)

Date

(Area Code) Daytime Telephone No.

SOCIAL SECURITY ADMINISTRATION

About The Privacy Act
Social Security is allowed to collect the
facts on this form under section 205 of the
Social Security Act. We need them to
quickly identify your record and prepare
the Statement you asked us for. Giving us
these facts is voluntary. However, without
them we may not be able to give you a
Statement. Neither the Social Security
Administration nor its contractor will use
the information for any other purpose.

See Revised Privacy Act Statement Attached

Paperwork Reduction Act Notice
This information collection meets the requirements of
44 U. S. C. §3507, as amended by Section 2 of the
Paperwork Reduction Act of 1995. You do not need to
answer these questions unless we display a valid
Office of Management and Budget control number.
We estimate that it will take about 5 minutes to read the
instructions, gather the facts and answer the questions.
You may send comments on our time estimate above to:
SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.
Send only comments relating to our time estimate to
this address, not the completed form.

Request for Social Security
Statement
Within four to six weeks after you return
this form, we will send you:
• a record of your earnings history;
• an estimate of how much you have paid
in Social Security taxes; and
• estimates of benefits you (and your
family) may be eligible for now and in
the future.
Please note: If you have been receiving a
Social Security Statement each year about
three months before your birthday, this
request will stop your next scheduled
mailing. You will not receive a scheduled
Statement until the following year.
We hope you will find the Statement useful
in planning your financial future. Remember,
Social Security is more than a program for
retired people. It helps people of all ages in
many ways. For example, it can help
support your family in the event of your
death and pay you benefits if you become
severely disabled.
If you have questions about Social Security
or this form, please call our toll-free
number, 1-800-772-1213.

SSA will insert the following revised Privacy Act Statement into the form at its next
scheduled reprinting:
Privacy Act Statement
Request for Social Security Statement

Sections 205(a), 205(c)(2), and 233 of the Social Security Act (42 U.S.C. § 405 and 433), the
Federal Records Act of 1950 (64 Stat. 583), and the Employment Health Benefit Act of 1992,
authorize us to collect the information contained on this form. The information you provide is
used to accurately identify your record and quickly prepare the statement you requested. Your
response is voluntary. However, failure to provide all or part of the requested information may
affect the processing of this form and could prevent us from issuing you a statement.
We rarely use this information provided on this form for any other purpose other than for the
reasons explained above. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office, the General Services
Administration, the National Archives and Records Administration, and the Department
of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, and investigative activities necessary to ensure the
integrity and improvement of Social Security programs.
We may also use this information you provided in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for Federally-funded and administered benefit programs.
A complete list of routine uses for this information is available in Systems of Records Notice,
entitled, Earnings Recording and Self-Employment Income System, Social Security
Administration, Office of Systems, 60-0059. The notice, additional information regarding this
form, and information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security office.