SSA-1709 - Current

Form SSA-1709 (10-2020) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 4
OMB No. 0960-0098

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.

1. 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 (10-2020) UF

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2. 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

Attorney Fees and
Other Expenses
Included in Weekly
Amount

Enter Type of Payments
Temporary
Partial

Total

Permanent
Partial

Total

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

Permanent Rating PendingDecision Expected by

Award Under AppealDecision 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?

Yes

No

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.)

Yes

No

What were the total number of years
of service (FICA and non-FICA)?

Total Years/Months

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? (If "No", go on to item 12.)
Total Years/Months
What were the total number of years
of service (FICA and non-FICA)?

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

Years/Months

Yes

No

Years/Months

Form SSA-1709 (10-2020) UF

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12. Remarks
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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

Title

Telephone No.
(include area code)

Date

Form SSA-1709 (10-2020) UF

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Privacy Act Statement
Collection and Use of Personal Information
Section 224 of the Social Security Act, as amended, allows us to collect this information. Furnishing us this
information is voluntary. However, failing to provide 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 will use the information you provide to determine the effect of the claimant’s workers’ compensation or
public disability benefit on their Social Security disability insurance benefits. We may also share your
information for the following purposes, called routine uses:
1. To third party contacts that may have information relevant to the Social Security Administration's
establishment or verification of information provided by representative payees or payee applicants.
2. To Federal, State, or local agencies for administering income maintenance or health
maintenance programs.
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) 60-0089,
entitled Claims Folders Systems, and 60-0090, entitled Master Beneficiary Record. Additional information
and a full listing of all our SORNs are available on our website at www.ssa.gov/privacy.

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.