Request for Social Security Statement - Internet Version- On Hold

Request for Social Security Statement

Internet Screens for SSA-7004 - Revised

Request for Social Security Statement - Internet Version- On Hold

OMB: 0960-0466

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0466 can be found here:

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Social Security Online - The Official Website of the U.S. Social Security Administration

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Social Security - Your Social Security Statement

noco t p i kS

Social Security Online
www.socialsecurity.gov

Social Security Statement
Home

Questions ?

Information about Your Statement
(Spanish)
Please Note:
This is your personal Statement
about your record with Social
Security. It does not include
information about benefits you
might qualify for on anyone
else's record. To ask about
whether you qualify on another
record, you can call our toll-free
number 1-800-772-1213 (TTY
1-800-325-0778) or call, write
or visit your local Social
Security office.

What is a Statement

PDF version of the
Sample Statement

Why automatic Statements?
Need to request a Statement?
Sample Statement

Questions about your Statement?
Your Benefits
Family Benefits
Two SSN's
Federal, State or Local Government Work
Government Pension Offset
Windfall Elimination Provision
Military or Railroad Service
Wrong Address
Earnings, Taxes and Credits
Work Outside the U.S.
Benefits on Another Record

Note: The "Bookmark"
icon above links to a
third-party service that
is not affiliated with the
Social Security
Administration.
[disclaimer]

Name/Birthdate Wrong
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Last reviewed or modified Tuesday Jan 26, 2010

http://www.socialsecurity.gov/mystatement/[2/17/2010 10:26:58 AM]

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Request your Social Security Statement

olCa r t neCo t p i kS

Social Security Online

Request a Social Security Statement

www.socialsecurity.gov

Information about
Requesting a Social Security
Statement
This service is available
(Eastern Time):

Monday through Friday - All Day (except 2:00 AM - 3:00
AM)
Saturday 5:00 AM - 11:00 PM
Sunday 8:00 AM - 10:00 PM
Holidays 5:00 AM - 11:00 PM
The Social Security Statement is a valuable document that
estimates your future Social Security benefits and tells you
how to qualify for those benefits.
This service allows you to transmit your request for a Social
Security Statement using an online form. However, we do
not send your Statement information back on the Internet.
Instead, you will receive a response to your request by U.S.
mail in 2-4 weeks.

Your Social Security
Statement will include:

To request your Social
Security Statement, you will
need:

Optional:

A record of your earnings history and an estimate of
how much you and your employer paid in Social
Security taxes; and
Estimates of benefits you (and your family) may be
eligible for now and in the future.

Your name as shown on your Social Security Card
Your Social Security Number
Your date of birth
Your place of birth
Your mother's maiden name - last name only (to help
identify you)
It will help us give you better benefit estimates if you also
give us:
Your last years' earnings and an estimate of your
current and future earnings
Age at which you plan to stop work

Some words about security:

SSA takes numerous steps to keep your accounts and
personal information secure, but you also play a role in

https://secure.ssa.gov/apps6z/isss/main.html[2/17/2010 10:27:16 AM]

Request your Social Security Statement

maintaining the security of your information. Here's what you
can do:
You may not always be at your own computer when
you request a Social Security Statement. Therefore,
it's important to exit your browser when you're finished
so others cannot see the information that you have
entered.
We recommend you use the built-in security features
Web browsers provide. Choosing certain security
settings and options will help protect the privacy of
your personal information. Security settings on your
browser vary depending on whether you are using a
Netscape or Microsoft product and by version of these
browsers. For more information consult the Help files
of your browser software.
Unless you have turned JavaScript off in your browser, you
will receive a warning after 25 minutes and you can extend
your time on the page. After the third warning, you must
move to another page, or your time will run out and your
work on that page will be lost.
If you are not comfortable sending information to us on the
Internet, you may download the Social Security Statement
request form (SSA-7004) and mail it to the address on the
form.

Want More Information?

If you have more questions about the Internet request for a
Social Security Statement, read our Frequently Asked
Questions.

Request Your Social
Security Statement Now

To request a Statement using the Internet, simply select the
button below and we will take you to the Online request
form. You will receive your Statement through regular mail
in about 2-4 weeks.

Please Note:

If you automatically receive a Social Security Statement
about three months before your birthday each year, this
request will stop your next scheduled mailing. You won't
receive another automatic Statement until the following
year.

Block access to your
personal information

If you want to prevent online and automated telephone
access to your personal information, you can block access
to your personal information.
Request a Social Security Statement

https://secure.ssa.gov/apps6z/isss/main.html[2/17/2010 10:27:16 AM]

Request your Social Security Statement

olCa r t neCo t p i kS

Social Security Online

Request a Social Security Statement

www.socialsecurity.gov

Please Enter Your
Information
Protecting Your Information

Form Approved: OMB No. 0960-0466
Expires: 9/31/2010

If you are in a public place, or are otherwise concerned
about others viewing your information, we strongly advise
exiting your Web browser upon completing your Statement
requests. If you use your browser BACK button, you will lose
data already entered and will have to re-enter it.
If you are using only the keyboard or using an assistive
device and need help, visit our Instructional page for
alternative views and navigation.
Note: If you select this link, you will leave this secure site
and go to a new browser window. You automatically will
return to this page when you close the new browser window.

Instructions

Complete the following web form to submit your Statement
request over the Internet. Please do NOT mail paper copies
of this web form.
All fields are mandatory unless otherwise noted. Please
do not use punctuation on this form.

Do you want to receive your
statement in English or
Spanish?
Please type your SSN, First
and Last Name, exactly as
shown on your Social
Security Card.

English

Spanish

Your Middle Initial is optional.
We cannot process your request without a valid Social
Security Number.

Your SSN:
(9 numbers)

First Name:
(1 - 15 Letters)

Middle Initial:
(None or 1 Letter)
OPTIONAL

Last Name:

https://secure.ssa.gov/apps6z/isss/main.html[2/17/2010 10:30:02 AM]

Request your Social Security Statement

(1 - 20 Letters)

Suffix:
OPTIONAL

Your Date of Birth:
Month, Day, Year

Place of Birth:

U.S. State or Territory

Select state or enter name of
foreign country of birth

Or Foreign Country

Your Gender:

Male

Female

Mother's Maiden Name:
(Last name only)
(1 - 20 letters)

Your Telephone Number:
(All numbers: "+" allowed for
foreign)

U.S. (

C/O Field: If you want to have your Statement
mailed to someone else, fill in the C/O field with the
name of that person.
Mailing Address: You must provide either a U.S.
Mailing Address OR a Foreign Address.
U.S. Street Address: Include the Street,
Apartment Number, PO Box or Rural Route.
Foreign Street Address: Include Street, City,
Province and Postal Code.

U.S.

APO/FPO Military select U.S.

In Care of Name:

Or Foreign

Address Instructions:

U.S. or Foreign Address:

)

C/O

(1-26 letters)
OPTIONAL
Do not type "C/O" in the field
below.

Mailing Address:
(1-22 letters or numbers per line)
Street Address (Check
Instructions): For U.S. Addresses,
do NOT include
https://secure.ssa.gov/apps6z/isss/main.html[2/17/2010 10:30:02 AM]

Foreign

Request your Social Security Statement

City, State, and ZIP Code

U.S. City: (If U.S. Address)
(1-19 letters)

State or Territory:
(If U.S. Address, select two letter
state abbreviation)

ZIP Code:

(If U.S. Address, 5 digit or 9 digit
zip code.)

Foreign Country:
(If Foreign Address, 1-21 letters)

Any Other Social Security
Numbers You Have Used:
(9 numbers)
OPTIONAL

This year's and last year's
earnings:

Last Year's Earnings:

Last year's earnings: Enter an EXACT or ESTIMATED
amount (blank or zero amount allowed).
This year's earnings: Enter an ESTIMATED amount
(blank or zero amount allowed).
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.
Show your earnings (wages and/or net selfemployment income) if covered by Social Security.
If your earnings for any year exceeded 6 digits, enter
"999999".

.00

(1 - 6 numbers)
OPTIONAL

This Year's Earnings:
(1 - 6 numbers)
OPTIONAL

Future Year's Earnings:

Enter the average yearly amount (not your total future
lifetime earnings) you think you will earn between now
and when you plan to stop working. If you expect that
amount to exceed 6 digits, enter "999999".
If you don't expect any significant changes, show
the same amount you are earning now.
Include performance or scheduled pay increases or

https://secure.ssa.gov/apps6z/isss/main.html[2/17/2010 10:30:02 AM]

Request your Social Security Statement

bonuses, but NOT cost-of-living increases.
Do not include an adjustment for inflation.
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 show NO earnings for future years, we will
estimate your benefit as if you had zero earnings
from next year on.

Future Average Yearly
Earnings:

.00

(1 - 6 numbers)
OPTIONAL

The age you plan to stop
working:

Enter the age at which you plan to stop working, up to
age 69.
If you do not know when you want to stop working, you
can leave this field blank.

Show the age you plan to
stop working:
OPTIONAL

The Privacy Act:
See Revised Privacy Act
Statement Attached

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
requested. Giving us these facts is voluntary. However,
without them we may not be able to give you a benefit
estimate statement. The Social Security Administration will
not use the information for any other purpose.

The Paperwork Reduction Act This information collection meets the clearance requirements
of 44 U.S.C. § 3507, as amended by section 2 of the
Statement:
See Revised PRA Statement
Attached

Paperwork Reduction Act of 1995. You are not required to
answer these questions unless we display a valid Office of
Management and Budget control number. We estimate it will
take you about 5 minutes to read the instructions, gather the
necessary facts, and answer the questions.
By sending this form, I certify that I am asking for action
to be taken on my Social Security record or the record of
a person who has expressly authorized this request. 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.

https://secure.ssa.gov/apps6z/isss/main.html[2/17/2010 10:30:02 AM]

Request your Social Security Statement

Anyone using this system expressly consents to
monitoring and is advised that if such monitoring
reveals possible evidence of criminal activity, SSA may
provide the evidence of such monitoring to law
enforcement officials.

SELECT AN ACTION BELOW
Select one of the options.

Continue

Cancel

https://secure.ssa.gov/apps6z/isss/main.html[2/17/2010 10:30:02 AM]

SSA will insert the following revised Privacy Act and PRA Statements into the Internet screens
upon OMB’s approval:
Privacy Act Statement
Section 205(a), 205(c0(2), and 233 of the Social Security Act (42 U.S.C. § 405 and 433), the
Federal Records Act of 1950 (64 Stat. 583), the Employee Retirement Income Security Act of
1974, the Employee Retirement Income Security Act of 1974, and the Coal Industry Retiree
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. This Privacy Act Statement and additional information regarding this
form’s use and disclosures are available on-line at www.socialsecurity.gov or at your local
Social Security office.

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 XX 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.

File Type	application/pdf
File Title	Social Security Online - The Official Website of the U.S. Social Security Administration
File Modified	2010-03-25
File Created	2010-02-17