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Fillable Printable Form SSA-7050

Fillable Printable Form SSA-7050

Form SSA-7050

Form SSA-7050

Form SSA-7050-F4 (10-2016) UF
Discontinue prior editions
Social Security Administration
REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION
Page 1 of 4
OMB No. 0960-0525
*Use This Form If You Need
1. Certified/Non-Certified Detailed Earnings Information
Includes periods of employment or self-employment
and the names and addresses of employers.
OR
2. Certified Yearly Totals of Earnings
Includes total earnings for each year but does not
include the names and addresses of employers.
DO NOT USE THIS FORM TO REQUEST
YEARLY EARNINGS TOTALS
Yearly earnings totals are FREE to the public
if you do not require certification.
To obtain FREE yearly totals of earnings,
visit our website at www.ssa.gov/myaccount.
Privacy Act Statement
Collection and Use of Personal Information
Section 205 of the Social Security Act, as amended, authorizes us to collect the information on this form. We will
use the information you provide to identify your records and send the earnings information you request.
Completion of this form is voluntary; however, failure to do so may prevent your request from being processed.
We rarely use the information in your earnings record for any purpose other than for determining your entitlement
to Social Security benefits. However, we may use it for the administration and integrity of Social Security programs.
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.
A complete list of routine uses for earnings information is available in our Systems of Records Notices entitled, the
Earnings Recording and Self-Employment Income System (60-0059), the Master Beneficiary Record (60-0090),
and the SSA-Initiated Personal Earnings and Benefit Estimate Statement (60-0224).
In addition, you may choose to pay for the earnings information you requested with a credit card.
31 C.F.R. Part 206 specifically authorizes us to collect credit card information. The information you provide about
your credit card is voluntary. Providing payment information is only necessary if you are making payment by credit
card. You do not need to fill out the credit card information if you choose another means of payment (for example,
by check or money order). If you choose the credit card payment option, we will provide the information you give us
to the banks handling your credit card account and the Social Security Administration's (SSA) account.
Routine uses applicable to credit card information, include but are not limited to:
(1) to enable a third party or an agency to assist Social Security to effect a salary or an administrative offset or to
an agent of SSA that is a consumer reporting agency for preparation of a commercial credit report in accordance
with 31 U.S.C. §§ 3711, 3717 and 3718; and (2) to a consumer reporting agency or debt collection agent to aid in
the collection of outstanding debts to the Federal Government.
A complete list of routine uses for credit card information is available in our System of Records Notice entitled, the
Financial Transactions of SSA Accounting and Finance Offices (60-0231). The notice, additional information
regarding this form, routine uses of information, and our programs and systems is 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,
asamended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions
unless we displaya valid Office of Management and Budget control number. We estimate that it will take about 11
minutes to read theinstructions, gather the facts, and answer the questions.Send onlycomments relating to
our time estimate above to: SSA,6401 Security Blvd, Baltimore, MD 21235-6401.
Page 2 of 4
Form SSA-7050-F4 (10-2016) UF
REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION
1. Provide your name as it appears on your most recent Social Security card or the name of the individual whose
earnings you are requesting.
First Name:Middle Initial:
Last Name:
-
-
One SSN per request
//
Other Name(s) Used
(Include Maiden Name)
2. What kind of earnings information do you need? (Choose ONE of the following types of earnings or SSA must return this request.)
Itemized Statement of Earnings $115
(Includes the names and addresses of employers)
If you check this box, tell us why you need this information below.
Year(s) Requested:to
Year(s) Requested:
to
Check this box if you want the earnings information
CERTIFIED for an additional $33.00 fee.
Certified Yearly Totals of Earnings $33
(Does not include the names and addresses of employers)
Yearly earnings totals are FREE to the public if you do not
require certification. To obtain FREE yearly totals of earnings,
visit our website at www.ssa.gov/myaccount.
Year(s) Requested:
to
Year(s) Requested:
to
3. If you would like this information sent to someone else, please fill in the information below.
I authorize the Social Security Administration to release the earnings information to:
Name
AddressState
CityZIP Code
4. I am the individual to whom the record pertains (or a person authorized to sign on behalf of that individual). I
understand that any false representation to knowingly and willfully obtain information from Social Security records is
punishable by a fine of not more than $5,000 or one year in prison.
Signature AND Printed Name of Individual or Legal Guardian
SSA must receive this form within 120 days from the date signed
Relationship (if applicable, you must attach proof)
Daytime Phone:
AddressState
CityZIP Code
Witnesses must sign this form ONLY if the above signature is by marked (X). If signed by mark (X), two witnesses to the signing who
know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the signature
line above.
1. Signature of Witness2. Signature of Witness
Address(Number and Street, City, State and ZIP Code)Address(Number and Street, City, State and ZIP Code)
/
/
/
/
Social Security Number (SSN)
Date of Birth:Date of Death:
Date
REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION
How do I get my earnings statement?
You must complete the attached form. Tell us the specific
years of earnings you want, type of earnings record, and
provide your mailing address. The itemized statement of
earnings will be mailed to ONE address, therefore, if you
want the statement sent to someone other than yourself,
provide their address in section 3. Mail the completed form
to SSA within 120 days of signature. If you sign with an "X",
your mark must be witnessed by two impartial persons who
must provide their name and address in the spaces provided.
Select ONE type of earnings statement and include the
appropriate fee.
1. Certified/Non-Certified Itemized Statement of Earnings
This statement includes years of self-employment or
employment and the names and addresses of
employers.
2. Certified Yearly Totals of Earnings
This statement includes the total earnings for each year
requested but does not include the names and
addresses of employers.
If you require one of each type of earnings statement, you
must complete two separate forms. Mail each form to SSA
with one form of payment attached to each request.
How do I get someone else's earnings statement?
You may get someone else's earnings information if you
meet one of the following criteria, attach the necessary
documents to show your entitlement to the earnings
information and include the appropriate fee.
1. Someone Else's Earnings
The natural or adoptive parent or legal guardian of a
minor child, or the legal guardian of a legally declared
incompetent individual, may obtain earnings information
if acting in the best interest of the minor child or
incompetent individual. You must include proof of your
relationship to the individual with your request. The proof
may include a birth certificate, court order, adoption
decree, or other legally binding document.
2. A Deceased Person's Earnings
You can request earnings information from the record of
a deceased person if you are:
• The legal representative of the estate;
• A survivor (that is, the spouse, parent, child, divorced
spouse of divorced parent); or
• An individual with a material interest (e.g., financial)
who is an heir at law, next of kin, beneficiary under the
will or donee of property of the decedent.
You must include proof of death and proof of your
relationship to the deceased with your request.
Is There A Fee For Earnings Information?
Yes. We charge a $115 fee for providing information for
purposes unrelated to the administration of our programs.
1. Certified or Non-Certified Itemized Statement of
Earnings
In most instances, individuals request Itemized
Statements of Earnings for purposes unrelated to our
programs such as a private pension plan or personal
injury suit. Bulk submitters may email OCO.Pension.
Fund@ssa.gov for an alternate method of obtaining
itemized earnings information.
We will certify the itemized earnings information for an
additional $33.00 fee. Certification is usually not
necessary unless you are specifically requested to obtain
a certified earnings record.
Sometimes, there is no charge for itemized earnings
information. If you have reason to believe your earnings
are not correct (for example, you have previously received
earnings information from us and it does not agree with
your records), we will supply you with more detail for the
year(s) in question. Be sure to show the year(s) involved
on the request form and explain why you need the
information. If you do not tell us why you need the
information, we will charge a fee.
2. Certified Yearly Totals of Earnings
We charge $33 to certify yearly totals of earnings.
However, if you do not want or need certification, you may
obtain yearly totals FREE of charge at
www.ssa.gov/myaccount. Certification is usually not
necessary unless you are advised specifically to obtain a
certified earnings record.
Method of Payment
This Fee Is Not Refundable. DO NOT SEND CASH.
You may pay by credit card, check or money order.
• Credit Card Instructions
Complete the credit card section on page 4 and
return it with your request form.
• Check or Money Order Instructions
Enclose one check or money order per request form
payable to the Social Security Administration and
write the Social Security number in the memo.
How long will it take SSA to process my request?
Please allow SSA 120 days to process this request. After
120 days, you may contact 1-800-772-1213 to leave an
inquiry regarding your request.
INFORMATION ABOUT YOUR REQUEST
You may use this form to request earnings information for only ONE Social Security Number (SSN)
Form SSA-7050-F4 (10-2016) UF
Page 3 of 4
Mail the completed form, supporting documentation,
and applicable fee to:
Social Security Administration
Division of Earnings and Business Services
P.O. Box 33011
Baltimore, Maryland 21290-3003
If using private contractor such as FedEx mail form,
supporting documentation and applicable fee to:
Social Security Administration
Division of Earnings and Business Services
6100 Wabash Ave.
Baltimore, Maryland 21215
How much do I have to pay for an Itemized Statement of Earnings?
CHECK ONE
Visa
MasterCard
American Express
Discover
Credit Card Holder's Name
(Enter the name from the credit card)
First Name, Middle Initial, Last Name
Credit Card Holder's Address
Number & Street
City, State, & ZIP Code
Daytime Telephone Number
Credit Card Number
Credit Card Expiration Date
Amount Charged
See above to select the correct fee for your request.
Applicable fees are $33, $115, or $148
SSA will return forms without the appropriate fee.
$
Credit Card Holder's Signature
DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY
Authorization
Name
Date
Remittance Control #
REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION
Where do I send my complete request?
• How much do I have to pay for Certified Yearly Totals of Earnings?
Certified yearly totals of earnings cost $33.00.You may obtain non-certified yearly totals FREE of charge at
www.ssa.gov/myaccount
. Certification is usually not necessary unless you are specifically asked to obtain
a certified earnings record.
Certified Itemized Statement of Earnings
$148.00
Non-Certified Itemized Statement of Earnings
$115.00
(MM/YY)
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)(
Page 4 of 4
Form SSA-7050-F4 (10-2016) UF
YOU CAN MAKE YOUR PAYMENT BY CREDIT CARD
As a convenience, we offer you the option to make your payment by credit card. However, regular credit card rules will
apply. You may also pay by check or money order. Make check payable to Social Security Administration.
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