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 worked 22 hours, enter the hours as follows:
If you worked 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

Privacy Act Statement
Retirement, Survivors, and Disability Insurance
Sections 203(h) and 205(a) of the Social Security Act, as amended, allow us to collect this
information. However, failing to provide all or part of the information may prevent us from
making an accurate and timely decision on your benefit amount.
We will use the information to ensure that we are paying beneficiaries correctly, to prevent
earnings-related overpayments, and to avoid erroneous withholding. We may also share your
information for the following purposes, called routine uses:
1. To a contractor for the purpose of collating, evaluating, analyzing, aggregating or otherwise
refining records when the Social Security Administration contracts with a private firm. (The
contractor shall be required to maintain Privacy Act safeguards with respect to such records.);
and
2. To the Department of State for administering the Social Security Act in foreign countries
through services and facilities of that agency.
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 (SORN)
60-0059, entitled Earnings Recording and Self-Employment Income Record, 60-0089, entitled
Claims Folder System, and 60-0090, entitled Master Beneficiary Record. Additional information
and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.
See Revised PRA Attached
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 10 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.

SSA will insert the following revised PRA Statement into the letters 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
10 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments regarding this burden estimate or any other aspect of this collection,
including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.