Form SSA-513 Request for Quarters of Coverage Based on Relationship

Form Approved
OMB No: 0960-0575

Social Security Administration

Date of Request:________________

REQUEST FOR QUARTERS OF COVERAGE (QC)
HISTORY BASED ON RELATIONSHIP
Complete the information below when requesting QC history for spouse(s) or parent(s) of a lawfully admitted
non-citizen applicant. Mail the form to the Social Security Administration, PO Box 17750, Baltimore, MD
21235-0001.
Print Name: (Last, First, Middle)

SSN

Date of Birth (MM-DD-YY)
-

-

Relationship to Applicant

NOTE: COMPLETE THE YEAR COLUMN AND CIRCLE THE PERTINENT QUARTER(S) FOR
THE YEAR. SSA WILL PROVIDE INFORMATION ONLY FOR YEARS AND QUARTERS YOU
INDICATE.
QC
QC PATTERN
PATTERN

QC PATTERN

YEAR

1ST Q 2ND Q 3RD Q 4TH Q

YEAR

1ST Q 2ND Q 3RD Q 4TH Q

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Form SSA-513 (12/2006)

(OVER)

Address (Number, City, State, Zip Code)
Contact Person's Name

Contact Person's Telephone Number

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 2 minutes to read the instructions, gather the facts, and answer the questions. The office is
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.

SSA-513 (12/2006)