Form SSA-L9790 Retirement, Survivors and Disability Insurance: Nonwork

Social Security Administration
Retirement, Survivors, and Disability Insurance
Return Address
Date:
Claim Number:

BENEFICIARY NAME
ADDRESS
CITY ST ZIP
We need updated information about your work to make sure that we pay you the right amount of
Social Security benefits.
What You Need To Do
Please complete the enclosed form to tell us about your work for [year]. Please return it as soon
as possible in the enclosed envelope. If we do not receive it within 30 days, we will assume that
you worked all months in [year].
Thank you for taking the time to complete the form. We may contact you again if we need more
information.
If You Have Questions
If you have any questions, please:


Visit our website at www.socialsecurity.gov to find general information about Social
Security.



Call us toll-free at 1-800-775-7802, 7:30 a.m. to 4:00 p.m. Monday through Friday. We
can answer most questions over the phone. If you are deaf or hard of hearing, our tollfree TTY number is 1-800-325-0778.



Write or visit any Social Security office. If you plan to visit an office, you may call
ahead to make an appointment. The office that serves your area is located at:
[FO ADDRESS]

Please have this letter with you if you call or visit an office. If you write, please include a copy
of the first page of this letter. It will help us answer your questions.

Acting Commissioner
of Social Security
Enclosures:
Earnings Estimate Form SSA-9790-SM
Envelope

Form Approved
OMB No. 0960-0369

Page 1

EARNINGS ESTIMATE
Your Monthly Earnings
Usually, if you make more than the earnings limit, which in [year] is $[AEA], we have to hold
back some of your Social Security. However, if we know how much you earned before taxes in
each month in [year] we may be able to pay you more.
The same is true of self-employed people. The difference is that we need to know how many
hours you worked in each month, instead of the amount of money you will earned.
For the following months in [year], you previously told us that you would not earn over $[MEA]
and would not work over 45 hours in self-employment.
1. If you worked for wages, place an “X” in the box under each month when you earned
$[MEA] or less. Do not put an “X” in the box for months you earned more than
$[MEA].
JAN

FEB

MAR

APR

MAY JUN

JUL

AUG

SEP

OCT

NOV

DEC

2. If you were self-employed, enter how many hours you worked in each month for [year].
Enter “0” if you did not work any hours for that month. Be sure to complete every box
for the whole year.
For example - if you work 22 hours, enter the hours as follows:
If you work 0 hours, enter the hours as follows:

JAN

JUL

FEB
B

AUG

0 2 2

0

MAR

APR

MAY

JUN

SEP

OCT

NOV

DEC

Please answer question 3 on the next page

Page 2
To help us make sure that we understand your answers, we would like to know if you stopped
working.

3. Did you stop working?
Show an “X” in the box next to your answer.
NO, I am still working.
YES, I stopped working.
If your answer is “YES”, show the date you stopped working.

/
Month

/
Day

Year

Your Signature
I declare under penalty of perjury that I have examined all the information on this form, and it is
true and correct to the best of my knowledge.
_______________________________
Signature

_______________
Date

Also, please give us a telephone number where we can reach you during the day. We may
contact you directly if we need more information to process this form.
__________________________________
Daytime Telephone Number

For SSA Use ONLY
Ext.

WB1 WB2 WB3

Page 3
Privacy Act Statement
Retirement, Survivors, and Disability Insurance
Sections 203(h)(3), (4), and 205(a) of the Social Security Act, as amended, authorize us to
collect the information requested on this form. We will use the information to ensure that we are
paying you correctly. The information you provide is voluntary. However, failure to provide us
with the requested information could prevent us from making an accurate and timely decision on
your benefit amount.
We rarely use the information provided on this form for any purpose other than for the reasons
stated above. However, we may use it for the administration and integrity of the Social Security
programs. We may also disclose the information provided on this form in accordance with
approved routine uses of the Privacy Act, 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 our records (e.g., to
the Government Accountability Office, General Services Administration, 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, or investigative activities necessary to assure the
integrity of Social Security programs.
We may also use the information you provide 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 or administered benefit programs and for repayment of
payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Records Notices
entitled, Earnings Recording and Self-Employment Income Record, 60-0059, Claims Folder
System, 60-0089, and Master Beneficiary Record, 60-0090. These notices, 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.

Page 4
PAPERWORK REDUCTION ACT STATEMENT
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 10 minutes to read the instructions, gather
the facts, and answer the questions. Send only comments on our time estimate above to: SSA,
6401 Security Blvd., Baltimore, MD 21235-0001.