Form SSA-1709 Request for Worker's Compensation/Public Disability Bene

Form Approved
OMB No. 0960-0098

SOCIAL SECURITY ADMINISTRATION

REQUEST FOR WORKERS' COMPENSATION/PUBLIC DISABILITY BENEFIT INFORMATION
TO:

REQUESTING OFFICE
SIGNATURE OF SSA OFFICIAL
TITLE
DATE

COMPUTER MATCHING STATEMENT: We may also use the information you give us when we match records by computer.
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 office. If you want to learn more about this, contact any Social Security Office.

l. IDENTIFICATION OF WORKER (To be completed by the Social Security Administration)
NAME OF WORKER

2. SOCIAL SECURITY

3. ADDRESS OF WORKER

4. EMPLOYER'S NAME AND ADDRESS

5. CLAIM NUMBER(S)

6. DATE OF INJURY OR ONSET OF DISEASE (if applicable)

I request and authorize release of information concerning
my claim for workers' compensation or other public
disability benefits to the Social Security Administration

Signature (If required by State or other entity)

INSTRUCTIONS FOR COMPLETION OF FORM
The Social Security Administration is required by law to reduce Social Security disability benefits when the worker is also
receiving workers' compensation, black lung benefits, or other public disability benefits. If your office has no record of a claim by
the worker named above, or if the worker filed a claim but was denied, please check the appropriate block below, sign on the
reverse, and return this form to the Social Security Administration.
No Record of Claim

Claim Denied - No Appeal

Claim Denied - Appeal Pending

If the claim by the named worker is pending, indicate when a decision is expected.
IF THE WORKER HAS EVER RECEIVED PERIODIC PAYMENTS OR A LUMP SUM AWARD, COMPLETE THE REVERSE
SIDE OF THIS FORM. IT IS IMPORTANT THAT ALL BENEFIT INFORMATION IS COMPLETED AS ACCURATELY AS
POSSIBLE BECAUSE THE WORKER'S SOCIAL SECURITY BENEFITS MAY BE REDUCED BASED ON THE
INFORMATION PROVIDED.
RETURN TO:
SOCIAL SECURITY ADMINISTRATION

Form SSA-1709 (05-2015) ef (05-2015)
Destroy Prior Editions

Page 1

II. INFORMATION REQUESTED (To be completed by addressee)
NOTE: A copy of the compensation decision, payment record, court order, award letter, etc. which clearly shows the
payment data requested below may be submitted in lieu of completing this form.
7. a. Periodic workers' compensation or public disability payments to worker
DATE
PAYMENT
EFFECTIVE

DATE
ENDED

WEEKLY
AMOUNT

ENTER TYPE OF PAYMENTS
ATTORNEY FEES
AND OTHER EXPENSES
TEMPORARY
PERMANENT
INCLUDED IN WEEKLY
AMOUNT
PARTIAL TOTAL PARTIAL TOTAL

b. Most recent payment stopped because (Check appropriate block).
Lump-Sum Settlement PendingDecision Expected By

Permanent Rating Pending Decision Expected By

Award Under Appeal Decision Expected By

Other (Explain in "Remarks").

8. a. Lump sum payment to worker
Date of Settlement(s)

Gross Amount(s)

Rate(s) per Week

Number of Weeks

Beginning Date

b. The following expenses were deducted from the gross amount:
1. Present and past medical expenses

$

2. Future medical expenses

$

3. Attorney fees

$

4. Other related expenses (Explain in "Remarks".)

$

9. Are the benefits reduced ( or will be reduced) because
of the worker's receipt of Social Security Benefits?
10. If the payments are not workers' compensation, (for example, disability retirement) and
the worker was a State or local government employee, were Social Security taxes
(that is, FICA taxes) paid on the worker's earnings? (If "No", go on to item 12.)
TOTAL YEARS /
What were the total number of years of MONTHS
service (FICA and non-FICA)?

Yes

No

Page 2

YEARS/MONTHS

Yes
No
(If "No", go on to item 12.)

TOTAL YEARS/ How many years was the worker engaged in
Federal employment covered by Social
MONTH
Security, including military service after
1956 , but not military service before 1957?
(OPM - Include deposit service.)

12. Remarks

Form SSA-1709 (05-2015) ef (05-2015)

No

How many years was the worker engaged in
employment "covered" by Social Security?

11. If the disability payments are not workers' compensation, but are being made under a
Federal law or plan, was any of the worker's service covered under Social Security
(i.e., FICA taxes were paid), including military service after 1956?
What were the total number of years of
service (FICA and non-FICA)?

Yes

YEARS/MONTHS

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 understand that anyone who knowingly
gives a false or misleading statement about a material fact in this information, or causes someone else to do so,
commits a crime and may be sent to prison, or may face other penalties, or both.
13. SIGNATURE OF PERSON COMPLETING THE FORM
TELEPHONE NO. (include area code)

TITLE

DATE

Privacy Act Statement

See Revised Privacy

Section 224 of the Social Security Act, as amended, authorizes us to collect this information.
We will use the information you
Act Statement
provide to determine the effect of the claimant’s workers’ compensation or public disability benefit on his or her Social Security
disability insurance benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information could prevent us from
making an accurate and timely decision on this claim and could affect the claimant’s benefits.
We rarely use the information you supply for any purpose other than to determine the effect of the claimant’s workers’
compensation or public disability benefit on his or her Social Security disability insurance benefits. 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 and 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 and improvement of
Social Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).
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 are available in Systems of Records Notices entitled, Claims Folders Systems,
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.

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 15 minutes to read the instructions, gather the facts,
and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You
can find your local Social Security office through SSA’s website at www.socialsecurity.gov. Offices are also listed under
U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213
(TTY 1-800-325-0778). 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.

Form SSA-1709 (05-2015) ef (05-2015)

Page 3