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.

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·

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
when you die 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 (TTY
1-800-325-0778).
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, mail it to:
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

Female

Form SSA-7004 (05-2012) EF (05-2012)
Destroy Prior Editions

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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)

0

(Dollars Only)

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.

X

Please sign your name (Do Not Print)

(Area Code) Daytime Telephone Number
Form SSA-7004 (05-2012) EF (05-2012)

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Date

Privacy Act Statement

See Revised PAS

Sections 205(a), 205(c)(2), and 233 of the Social Security Act (42 U.S.C. § 405 and 433), the Federal
Records Act of 1950 (64 Stat. 583), and the Employment Health Benefit Act of 1992, authorize us to collect
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 the information you provide on this form for any purpose other than for the reasons explained
above. However, we may use it for the administration and integrity of Social Security programs. We also
may 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 also may 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
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 and information regarding our programs and systems are available online at
www.socialsecurity.gov or at your local Social Security office.

See Revised PRA
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 (05-2012) EF (05-2012)

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SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 205(c)(2)(A) and 1143(a)(2) of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent the issuance of a Social Security statement.
We will use the information to accurately identify your Social Security earnings record, extract
the recorded earnings history, and to produce the requested statement. We may also share your
information for the following purposes, called routine uses:
1. To Federal, State, or local agencies for the purpose of validating Social Security numbers
used in administering cash or non-cash income maintenance or health maintenance
programs; and
2. To Federal, State, or local agencies for determining alien applicants' eligibility for benefit
programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORNs) 60-0059, entitled Earnings Recording and Self- Employment Income System, and 600224, entitled SSA-Initiated Personal Earnings and Benefit Estimate Statement. Additional
information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 (OMB) control number. We estimate that it will take about 5
minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.