Fillable Printable Request for Social Security Statement Template
Fillable Printable Request for Social Security Statement Template
Request for Social Security Statement Template
Form Approved
SP
OMB No. 0960-0466
Request for Social Security Statement
Please check this box if you want9. Do you want us to send the statement:For items 6 and 8 show only earnings covered
by Social Security. Do NOT include wages from
State, local or Federal Government employment
that are NOT covered for Social Security or that
are covered ONLY by Medicare.
• To you? Enter your name and mailing
address
to get your statement in Spanish
instead of English.
• To someone else (your accountant,
pension plan, etc.)? Enter your name with
''c/o'' and the name and address of that
person or organization.
Please print or type your answers. When you
have completed the form, fold it and mail it to us.
(If you prefer to send your request using the
Internet, contact us at www.ssa.gov)
6. Show your actual earnings (wages and/or net
self-employment income) for last year and
your estimated earnings for this year.
''C/O'' or Street Address (Include Apt. No., P.O. Box, Rural Route)
A. Last year's actual earnings: (Dollars Only)
1. Name shown on your Social Security card:
00
Street Address
.
$
,
B. This year's estimated earnings: (Dollars Only)
Street Address (If Foreign Address, enter City, Province, Postal Code)
First NameMiddle Initial
00
.
$
,
U.S. City, State, Zip code (If Foreign Address, enter Name of Country)
Last Name Only
7. Show the age at which you plan to stop
working.2. Your Social Security number as shown on
your card:
NOTICE:
I am asking for information about my own Social
Security record or the record of a person I am
authorized to represent. I understand that if I
deliberately request information under false
pretenses, I may be guilty of a Federal crime and
could be fined and/or imprisoned. I authorize you
to use a contractor to send the Social Security
Statement to the person and address in item 9.
(Show only one age)
8. Below, show the average yearly amount (not
your total future lifetime earnings) that you
think you will earn between now and when
3. Your date of birth (Mo.-Day-Yr.)
you plan to stop working. Include
performance or scheduled pay increases or
bonuses, but not cost-of-living increases.
If you expect to earn significantly more or less
in the future due to promotions, job changes,
part-time work, or an absence from the work
force, enter the amount that most closely
reflects your future average yearly earnings.
4. Other Social Security numbers you have used:
If you don't expect any significant changes,
show the same amount you are earning now
(the amount in 6B).
Please sign your name (Do Not Print)
MaleFemale5. Your Sex:Future average yearly earnings: (Dollars Only)
Date(Area Code)Daytime Telephone No.
00
.
$
,
Form SSA-7004-SM (6-2002) EF (08-20
02Destroy prior editions
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SOCIAL SECURITY ADMINISTRATION
Request for Social Security
About The Privacy Act Social Security is allowed to
collect the facts on this form under section 205 of the
Social Security Act. We need them to quickly identify
your record and prepare the statement you asked us for.
Giving us these facts is voluntary. However, without
them we may not be able to give you a statement.
Neither the Social Security Administration nor its
contractor will use the information for any other
purpose.
Statement
Thank you for requesting this statement.
After you complete and return this form, we will --
within 4 to 6 weeks -- send you:
• a record of your earnings history and an
estimate of how much you have paid in
Social Security taxes, and
• estimates of benefits you (and your family)
may be eligible for now and in the future.
We're pleased to furnish you with this information and
we hope you'll find it useful in planning your financial
future.
Paperwork Reduction Act Notice and Time It Takes
Statement
The Paperwork Reduction Act of 1995 requires us to
notify you that this information collection is in
accordance with the clearance requirements of section
3507 of the Paperwork Reduction Act of 1995. We may
not conduct or sponsor, and you are not required to
respond to, a collection of information unless it displays
a valid OMB control number. We estimate that it will
take about 5 minutes to complete this form. This
includes the time it will take to read the instructions,
gather the necessary facts and fill out the form.
Social Security is more than just a program for retired
people. It helps people of all ages in many ways. Whether
you're young or old, male or female, single or married --
Social Security can help you when you need it most. It
can help support your family in the event of your death
and pay you benefits if you become severely disabled.
Mail completed form to:
Social Security Administration
Wilkes Barre Data Operations Center
P.O. Box 7004
Wilkes Barre, PA 18767-7004
If you have questions about Social Security or this form,
please call our toll-free number, 1-800-772-1213.
