Form SSA-L9790 Retirement, Survivors and Disability Insurance: Nonwork

Social Security Administration
Retirement, Survivors and Disability Insurance
Important Information

Presort_Sequence

First_Name Middle_Name Last_Name
Delivery_Address
Alternate_1_Address
Alternate_2_Address
City, State ZIP4

Date: July 24, 2010
Claim Number: AccountNumber BIC

ZIP4DP_Combo
I am writing to ask your help in making sure that we are paying you the correct
amount of Social Security benefits. We need you to give us current information
about your work for TaxYear.
The enclosed form has some questions about your work for TaxYear. After you
complete it, please mail it in the enclosed envelope. If we do not receive this information
within 30 days, we will assume that you worked all months in TaxYear.
Thank you for taking the time to assist us. We would like to give you the best possible
service and hope that you find this form a convenient way to inform us about your work.
If you have any questions, you can call us toll free at 1-800-775-7802, 7:30 a.m. to
4:00 p.m. Monday through Friday. We can answer most questions over the phone.
Our busiest times are the first week of the month and Mondays. So, we may be
able to handle your call more quickly if you can call us at other times. If you prefer
to visit or call one of our offices, use the 800 number and we can give you the office
address and telephone number. Please have this letter with you if you call or visit
an office. It will help us answer your questions.

Sincerely,

Commissioner
Social Security Administration

Enclosures:
Nonwork Months Form SSA-L9790-SM
Envelope

Form SSA-L9790-SM (7-2010)

Form Approved
OMB No. 0960-0369

AccountNumber BIC
FullRetirementAge (1)

Your Monthly Earnings
Usually, if you make more than the earnings limit, which in TaxYear is $AEA,
we have to hold back some of your Social Security. But if we know how much
you earned before taxes in each month in TaxYear, we may be able to pay you more.
The same is true of self-employed people. The difference is that we need to know
how many hours you worked in each month, instead of the amount of money you
earned.

NonWorkMonths

1.

If you worked for wages, put an “X” in the box under
each month when you earned $MEA or less. Be sure
to do it for the whole year.
JAN

JUL AUG SEP

OCT NOV DEC

If you were self-employed, how many hours did you work
in each month in TaxYear? Be sure to put something
down for each month.
Show your hours in the boxes below.
JAN

FEB MAR APR MAY JUN

JUL AUG SEP

OCT NOV DEC

Please answer question 3 on the next page.

Page1Barcode

Form SSA-L9790-SM (7-2010)

*AccountNumber

2.

FEB MAR APR MAY JUN

AccountNumber

For the following months in TaxYear, you previously told us that you would not
earn over $MEA and would not work over 45 hours in self-employment.

TOE 220 861006 PPSC

First_Name Middle_Name Last_Name
DateOfEntitlementCurrent

*861006*

Page 1

Page 2

To help us make sure that we understand your answers, we would like to
know if you stopped working in TaxYear.

3.

Did you stop working in TaxYear?
Show an “X” in the box next to your answer.

NO
YES,

I stopped working in TaxYear.

If you answered “yes”, please show the date you last worked in the space
below.

/
Month / Day

/
/

Year

Remember, you need to return this form within 30 days.
Please sign this form in the space below, and send it back to us in the
enclosed envelope. And again thank you for your help.
I declare under penalty 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.
Your Signature

Date

Also, please give us a telephone number where we can reach you during the day.

Area Code

Telephone Number

For SSA Use ONLY
Ext.

Page2Barcode

WB 1 WB 2 WB 3

Form SSA-L9790-SM (7-2010)

Page 3

PRIVACY ACT STATEMENT
See Revised Privacy Act Attached
The Social Security Administration (SSA) is authorized to collect information on
this form under section 205 (a) and section 203 (h) (3), (4) of the Social Security Act.
Giving us this information is voluntary. You do not have to do it, but we may not be
paying you the right amount unless you give us this information.
We use the information you give us to insure that we are paying you correctly.
However, we may share this information with another person or government agency
to manage the Social Security program or other programs that must be coordinated
with the SSA.
We may also use the information you give us in computer matching programs.
Matching programs compare our records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove
that a person qualifies for benefits paid by the Federal Government. The law allows
us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be
used or given out are available in Social Security offices. If you want to learn more
about this, contact any Social Security office.
PAPERWORK REDUCTION ACT STATEMENT
Paperwork Reduction Act Statement - 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 10 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments on our time estimate above to: SSA, 6401
Security Blvd., Baltimore, MD 21235-0001.

Form SSA-L9790-SM (7-2010)

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
reprinting:
Privacy Act Statement
Retirement, Survivors, and Disability Insurance
Sections 203(h)(3), (4), and 205(a) of the Social Security Act, as amended, authorize us to
collect the information requested on this form. We will use the information to ensure that we are
paying you correctly. The information you provide is voluntary. However, failure to provide us
with the requested information could prevent us from making an accurate and timely decision on
your benefit amount.
We rarely use the information provided on this form for any purpose other than for the
reasons stated above. However, we may use it for the administration and integrity of Social
Security programs. We may also disclose the information provided on this form in accordance
with approved routine uses of the Privacy Act, 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 our records (e.g.,
to the Government Accountability Office, General Services Administration, 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, or investigative activities necessary to assure the
integrity of Social Security programs.

We may also use the information you provide 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 or administered benefit programs and for repayment
of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Records Notices
entitled, Earnings Recording and Self-Employment Income Record, 60-0059, Claims Folder
System, 60-0089, and Master Beneficiary Record, 60-0090. These notices, 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.