Form SSA-L9781 Retirement, Survivors and Disability Insurance: Earnings

Social Security Administration
Retirement, Survivors, and Disability Insurance
Return Address
Date:
Claim Number:

BENEFICIARY NAME
ADDRESS
CITY ST ZIP

We need updated information about your work to make sure that we pay you the right amount of
Social Security benefits. Earlier, you told us that your earnings this year would be about
[amount]. We want to review your estimate since your plans may have changed. We also need
to know about your work plans for [year].
What You Need To Do
Please complete the enclosed form to tell us about your work. Please return it as soon as
possible in the enclosed envelope.
Thank you for taking the time to complete the form. We may contact you again if we need more
information to process your form.
If You Have Questions
If you have any questions, please:


Visit our website at www.socialsecurity.gov to find general information about Social
Security.



Call us toll-free at 1-800-772-1213 or call your local office at [phone]. We can answer
most questions over the phone. If you are deaf or hard of hearing, our toll-free TTY
number is 1-800-325-0778.



Write or visit any Social Security office. If you plan to visit an office, you may call
ahead to make an appointment. The office that serves your area is located at:
[FO ADDRESS]

Please have this letter with you if you call or visit an office. If you write, please include a copy
of the first page of this letter. It will help us answer your questions.

Acting Commissioner
of Social Security
Enclosures:
Earnings Estimate Form SSA-9781-SM
Envelope

Estimate Your Earnings for [year] and [year]
We have put together a list of questions that will help you update your earnings estimate. Please
answer them carefully. Before you answer our questions, we want to talk briefly about how to
estimate your earnings.
How to Estimate Your Earnings
It may not be easy for you to figure ahead of time how much you will make in [year] and [year].
However if you keep these pointers in mind, you should have no problem.


If you are paid wages, base your estimate on what you expect to earn before taxes or
other deductions for the whole year. Be sure to include bonuses, vacation pay, sick pay,
tips of $20 or more a month, and any contribution that you make from your salary to a tax
deferred savings plan.



Drop from your estimate any money you will get from your employer this year for work
you did last year or before. Also, do not include:
-

Social Security, railroad or civil service retirement, veterans, black lung, or public
assistance benefits
Pensions and other retirement payments which are not reported on your W-2 form
Investment income
Interest from savings accounts
Life insurance annuities and dividends
Gifts or inheritances
Gain (or loss) from the sale of capital assets
Rental income
Unemployment or worker’s compensation
Jury duty payments



If you are self-employed, base your estimate on what you think your net earnings will be
– just like on your tax return. If you become entitled to Social Security benefits before
[year]:
- Do not include in your estimate any Federal agricultural program payments you
expect in [year]; and
- Do not include self-employment income received in [year] from carry-over crops for
work you did before you became entitled to Social Security benefits.



If you get both wages and income from self-employment, add the two amounts together.
The total is your estimate.

(OVER)

Page 2


You will reach full retirement age in [month] [year].
Beginning with the month of full retirement age, the earnings limit no longer applies. If
you will reach full retirement age in [date], you do not have to complete question 5
regarding your earnings for [year].
People who reach full retirement age in February through December [year] should
exclude from their estimate of yearly earnings for [year] any wages earned in the month
they reach full retirement age and all following months. You should prorate selfemployment income based on the number of months under full retirement age. That is,
divide expected net earnings (or loss) for [year] by the number of months of selfemployment and multiply this result by the number of months in [year] before you reach
full retirement age.

Now, you are ready to answer the following questions about your earnings. Again, it is
important for us to hear from you.

Form Approved
OMB No. 0960-0369

Page 1

EARNINGS ESTIMATE

1. Earlier, you told us you will earn [amount] this year. How much do you now think you
will earn in [year]?
Show your earnings for the whole year, including amounts you will earn both before and
after you filed for Social Security benefits.
Show your answer in the space below. Use dollar amounts only; round cents to the nearest
whole dollar.

+

Wages

$

,

,

Net Self-Employment

$

,

,

$

,

,

= Total Earnings
Your Monthly Earnings

So far you have figured out how much you plan to earn in [year]. Now you need to go back and
estimate how much you will earn each month. We need to know this because we pay you based
on how much you will earn each month.
It works like this. Usually, if you make more than the earnings limit, which in [year] is $[AEA],
we have to hold back some of your Social Security. However, if we know how much you earned
before taxes in each month in [year] 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.
For the following months in [year], you previously told us that you would not earn over $[MEA]
and would not work over 45 hours in self-employment.
2. If you worked for wages, place an “X” in the box under each month when you earned
$[MEA] or less. Do not put an “X” in the box for months you earned more than
$[MEA].
JAN

FEB

MAR

APR

MAY JUN

Please go on to the next question

JUL

AUG

SEP

OCT

NOV

DEC

Page 2
3. If you were self-employed, enter how many hours you worked in each month for [year].
Enter “0” if you did not work any hours for that month. Be sure to complete every box
for the whole year.
For example - if you work 22 hours, enter the hours as follows:
If you work 0 hours, enter the hours as follows:

JAN

FEB
B

JUL

AUG

0 2 2

0

MAR

APR

MAY

JUN

SEP

OCT

NOV

DEC

Your Retirement Plans
To help us make sure that we understand your answers, we would like to know if you have
retired, or if you plan to retire this year.
4. Have you retired, or do you plan to retire in [year]?
If you retired, or plan to retire from your regular (full-time) employment in [year], answer
“YES” to this question even if you work or plan to work part-time.
Show an “X” in the box next to your answer.

NO, I have not retired and I am not going to retire this year.
YES, I have retired, or plan to retire this year.
If you answered “yes”, please show your retirement date in the space below.

/
Month /

/
Day /

Year

Please answer question 5 on the next page

Page 3
Our Last Question
If you will reach full retirement age in January [year], you do not have to complete this
question.
Our last question is about your earnings in [year]. Please look ahead and estimate how much
you plan to earn next year. We will use this information to decide how much we can pay you in
[year].


If you do not plan to work in [year], show “0” as your estimated earnings amount



If you will attain full retirement age in [year], include only your earnings prior to the
month you become full retirement age.

You must answer this question. If you do not enter an amount on question 5, we will use
your estimate for [year] to decide how much to pay you in [year].
5. How much do you think you will earn in [year]?
Show your answer in the space below. Use dollar amounts only; round cents to the nearest
whole dollar.
$

,

,

Your Signature
I declare under penalty of perjury that I have examined all the information on this form, and it is
true and correct to the best of my knowledge.
_______________________________
Signature

_______________
Date

Also, please give us a telephone number where we can reach you during the day. We may
contact you directly if we need more information to process this form.
__________________________________
Daytime Telephone Number

For SSA Use ONLY
Ext.

WB1 WB2 WB3

Page 4
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 the 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.

Page 5
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.