Request for Correction of Earnings Record (Paper)

SSA will insert the following revised Privacy Act Statement into the form as soon as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), (c)(2), (4), (5), and 233 of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may affect the accuracy of your earnings record.
We will use the information to correct your earnings record. We may also share your
information for the following purposes, called routine uses:
1. To employers or former employers, including State Social Security administrators, for
correcting and reconstructing State employee earnings records and for Social Security
purposes.
2. To officers and employees of Federal, State or local agencies upon written request in
accordance with the Internal Revenue Code (IRC) U.S.C. 6103(I)(7)), tax return
information (e.g., information with respect to net earnings from self-employment, wages,
payments of retirement income which have been disclosed to the Social Security
Administration, and business and employment addresses) for purposes of, and to the
extent necessary in, determining an individual’s eligibility for, or the correct amount of,
benefits under certain programs listed in the IRC.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0059, entitled Earnings Recording and Self-Employment Income System.
Additional information and a full listing of all our SORNs and applicable routine uses are
available on our website at www.socialsecurity.gov/foia/bluebook.