Form SSA-7004 Request for Social Security Statement (paper version)

Form Approved
OMB No. 0960-0466

Social Security Administration

Request for Social Security Statement
Within four to six weeks after you return this form, we will send you:
• a record of your earnings history;
• 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.
Please note: If you have been receiving a Social Security Statement each year about three months before
your birthday, this request will stop your next scheduled mailing. You will not receive a scheduled Statement
until the following year.
We hope you will find the Statement useful in planning your financial future. Remember, Social Security is more than
a program for retired people. It helps people of all ages in many ways. For example, it can help support your family in
the event of your death and pay you benefits if you become severely disabled.
If you have any questions about Social Security or this form, please call our toll-free number, 1-800-772-1213.
Please check this box if you want to get your Statement in Spanish instead of English.
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, go to www.socialsecurity.gov.
Social Security Administration
Wilkes Barre Data Operations Center
P.O. Box 7004
Wilkes Barre, PA 18767-7004
1. Name shown on your Social Security card:
First Name:

Middle Initial:

Last Name only:

-

2. Your Social Security number as shown on your card:

/

3. Your date of birth (Month-Day-Year):

/

4. Other Social Security numbers you have used:

5. Your Sex:

Male

Form SSA-7004 (xx-xxxx) EF (xx-xxxx)
Destroy Prior Editions

-

Female
Page 1

-

-

-

-

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 by Social Security or that are covered ONLY by Medicare.
6. Show your actual earnings (wages and/or net self-employment income) for last year and your estimated earnings
for this year.

.0

$

A. Last year's actual earnings:
B. This year's estimated earnings:

0

.0

$

(Dollars Only)
(Dollars Only)

0

7. Show the age at which you plan to stop working:
(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 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.
If you don't expect any significant changes, show the same amount you are earning now (the amount in 6B).
Future average yearly earnings:

.0

$

0 (Dollars Only)

9. Do you want us to send the Statement:

• To you? Enter your name and mailing address.
• To someone else (your accountant, pension plan, etc.)? Enter your name with "c/o" and the name and address
of that person or organization.
"C/O" or Street Address (Include Apt. No., P.O. Box, Rural Route)
Street Address
Street Address (If Foreign Address, enter City, Province, Postal code)
U.S. City, State, ZIP code (If Foreign Address, enter Name of Country only)
NOTICE:
I am asking for information about my own Social Security record or the record of a person I am authorized to
represent. I declare under penalty of perjury that I have examined all the information this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge. I authorize you to
use a contractor to send the Social Security Statement to the person and address in item 9.

u

Please sign your name (Do Not Print)

(Area Code) Daytime Telephone Number
Form SSA-7004 (xx-xxxx) EF (xx-xxxx)

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Date

Privacy Act Statement

See Revised
Sections 205(a), 205(c)(2), and 233 of the Social Security Act (42 U.S.C. § 405 and
433),Actthe Federal
Privacy
Records Act of 1950 (64 Stat. 583), and the Employment Health Benefit Act of 1992,
authorize us to collect
Statement
the information contained on this form. The information you provide is used to accurately identify your
record and quickly prepare the statement you requested. Your response is voluntary. However, failure to
provide all or part of the requested information may affect the processing of this form and could prevent us
from issuing you a statement.
We rarely use this information provided on this form for any other purpose other than for the reasons
explained above. 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, the General Services Administration, the National
Archives and Records Administration, and the 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, and investigative activities necessary to ensure the
integrity and improvement of Social Security programs.

We may also use this information you provided 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
and administered benefit programs.
A complete list of routine uses for this information is available in Systems of Records Notice, entitled,
Earnings Recording and Self-Employment Income System, Social Security Administration, Office of
Systems, 60-0059. The notice, 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 Notice
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 5 minutes to read the
instructions, gather the facts and answer the questions. 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-7004 (xx-xxxx) EF (xx-xxxx)

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