Form Approved OMB No. 0960-0525 REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION *Use This Form If You Need 1. Certified/Non-Certified Detailed Earnings Information Includes periods of employment or self-employment and the names and addresses of employers. OR 2. Certified Yearly Totals of Earnings Includes total earnings for each year but does not include the names and addresses of employers. DO NOT USE THIS FORM FOR: Non-certified yearly totals of earnings This service is free to the public. These totals can be obtained by calling 1-800-772-1213 to receive Form SSA-7004, Request for Earnings and Benefit Estimate Statement. PRIVACY ACT NOTICE: We are authorized to collect this information under section 205 of the Social Security Act, and the Federal Records Act of 1950 (64 Stat. 583). It is needed so we can identify your records and prepare the statement you request. You do not have to furnish the information, but failure to do so may prevent your request from being processed. 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 11 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). 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. INFORMATION ABOUT YOUR REQUEST • How Do I Get This Information? • You need to complete the attached form to tell us what information you want. Can I Get This Information For Someone Else? • Yes, if you have their written permission. For more information, see page 3. Who Can Sign On Behalf Of The Individual? • The parent of a minor child, or the legal guardian of an individual who has been declared legally incompetent, may sign if he/she is acting on behalf of the individual. Is There A Fee For This Information? 1. Certified/Non-Certified Detailed Earnings Information Yes, we usually charge a fee for detailed information. In most cases, this information is used for purposes NOT directly related to Social Security such as for a private pension plan or personal injury suit. The fee chart on page 3 gives the amount of the charge. Sometimes, there is no charge for detailed information. If you have reason to believe your earnings are not correct (for example, you have previously received earnings information from us and it does not agree with your records), we will supply you with more detail for the period in question. Occasionally, earnings amounts are wrong because an employer did not correctly report earnings or earnings are credited to the wrong person. In situations like these, we will send you detailed information, at no charge, so we can correct your record. Be sure to show the year(s) involved on the request form and explain why you need the information. If you do not tell us why you need the information, we will charge a fee. We will certify the detailed earnings information for an additional fee of $15.00. Certification is usually not necessary unless you plan to use the information in court. 2. Certified Yearly Total of Earnings Yes, there is a fee of $15 to certify yearly totals of earnings. Cetification is usually not necessary unless you plan to use the information in court. 3. Method of Payment Enclose a check or money order for the entire fee required. Payment can also be made by credit card. To do so, complete page 4 of this form and return it with your request form. Form SSA-7050-F4 (01-2004) EF (09-2008) Destroy prior editions American LegalNet, Inc. www.FormsWorkflow.com REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION 1. From whose record do you need the earnings information? Print the Name, Social Security Number (SSN), and date of birth below. Name Social Security Number Other Name(s) Used (Include Maiden Name) Date of Birth (Mo/Day/Yr) 2. What kind of information do you need? For the period(s)/year(s): Detailed Earnings Information (If you check this block, tell us below why you need this information.) Certified Total Earnings For Each Year. For the year(s): (Check this box only if you want the information certified. Otherwise, call 1-800-772-1213 to request Form SSA-7004, Request for Earnings and Benefit Estimate Statement) 3. If you owe us a fee for this detailed earnings information, enter the amount due using the chart on page 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Do you want us to certify the information? If yes, enter $15.00 A. $ Yes No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ADD the amounts on lines A and B, and enter the TOTAL amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. $ C. $ • You can pay by CREDIT CARD by completing and returning the form on page 4, or • Send your CHECK or MONEY ORDER for the amount on line C with the request and make check or money order payble to "Social Security Administration" • DO NOT SEND CASH. 4. I am the individual to whom the record pertains (or a person who is authorized to sign on behalf of that individual). I understand that any false representation to knowingly and willfully obtain information from Social Security records is punishable by a fine of not more than $5,000 or one year in prison. SIGN your name here (Do not print) > Date Daytime Phone Number (Area Code) (Telephone Number) 5. Tell us where you want the information sent. (Please print) Name Address City, State & Zip Code 6. Mail Completed Form(s) To: Social Security Administration Division of Earnings Record Operations P.O. Box 33003 Baltimore Maryland 21290-3003 Form SSA-7050-F4 (01-2004) EF (09-2008) Exception: If using private contractor (e.g., FedEx) to mail form(s), use: Social Security Administration Division of Earnings Record Operations 300 N. Greene St. Baltimore Maryland 21290-0300 2 American LegalNet, Inc. www.FormsWorkflow.com REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION How Much Do I Have to Pay For Detailed Earnings? 1. Count the number of years for which you need detailed earnings information. Be sure to add in both the first and last year requested. However, do not add in the current calendar year since this information is not yet available. 2. Use the chart below to determine the correct fee. Number of Years Requested Fee Number of Years Requested Fee Number of Years Requested Fee 1 $15.00 15 $43.75 28 $64.50 2 17.50 16 45.50 29 66.00 3 20.00 17 47.25 30 67.50 4 22.50 18 49.00 31 68.75 5 25.00 19 50.75 32 70.00 6 27.00 20 52.50 33 71.25 7 29.00 21 54.00 34 72.50 8 31.00 22 55.50 35 73.75 9 33.00 23 57.00 36 75.00 10 35.00 24 58.50 37 76.25 11 36.75 25 60.00 38 77.50 12 38.50 26 61.50 39 78.75 13 40.25 27 63.00 40 80.00 14 42.00 For Requests Over 40 Years, Please Add 1 Dollar for Each Additional Year. • Whose Earnings Can Be Requested 1. Your Earnings 3. A Deceased Person's Earnings You can request earnings information from the record of a deceased person if you are the legal representative of the estate, a survivor (that is, the spouse, parent, child, divorced spouse of divorced parent), or an individual with a material interest (example-financial) who is an heir at law, next of kin, beneficiary under the will or donee of property of the decedent. You can request earnings information from your own record by completing the attached form; we need your handwritten signature. If you sign with an "X", your mark must be witnessed by two disinterested persons who must sign their name and address. 2. Someone Else's Earnings Proof of death must be included with your request. Proof of appointment as representative or proof of your relationship to the deceased must also be included. You can request earnings information from the record of someone else if that person tells us in writing to give the information to you. This writing or "authorization" must be presented to us within 60 days of the date it was signed by that person. Form SSA-7050-F4 (01-2004) EF (09-2008) 3 American LegalNet, Inc. www.FormsWorkflow.com YOU CAN MAKE YOUR PAYMENT BY CREDIT CARD As a convenience, we offer you the option to make your payment by credit card. However, regular credit card rules will apply. You may also pay by check or money order. Please fill in all the information below and return this form along with your request to: Exception: If using private contractor (e.g., FedEx) to mail form(s), use: Social Security Administration Division of Earnings Record Operations P.O. Box 33003 Baltimore Maryland 21290-3003 Social Security Administration Division of Earnings Record Operations 300 N. Greene St. Baltimore Maryland 21290-0300 Note: Please read Paperwork/Privacy Act Notice Visa American Express MasterCard CHECK ONE Discover Diners Card Credit Card Holder's Name (Enter the name from the credit card) First Name, Middle Initial, Last Name Number & Street Credit Card Holder's Address City, State, & Zip Code Daytime Telephone Number Area Code Credit Card Number Telephone Number -- Credit Card Expiration Date Month Amount Charged -- -- Year $ Credit Card Holder's Signature Authorization DO NOT WRITE IN THIS SPACE OFFICE USE ONLY Name Date Remittance Control # PRIVACY ACT NOTICE The Social Security Administration (SSA) has authority to collect the information requested on this form under section 205 of the Social Security Act. Giving us this information is voluntary. You do not have to do it. We will need this information only if you choose to make payment by credit card. You do not need to fill out this form if you choose another means of payment (for example, by check or money order). If you choose the credit card payment option, we will provide the information you give us to the banks handling your credit card account and SSA's account. We may also provide this information to another person or government agency to comply with federal laws requiring the release of information from our records. You can find these and other routine uses of information provided to SSA listed in the Federal Register. If you want more information about this, you may call or write any Social Form SSA-7050-F4 (01-2004) EF (09-2008) 4 American LegalNet, Inc. www.FormsWorkflow.com