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Privacy Act Statement
Sections 205(a), 205(c)(2), and 1143(a)(2) of the Social Security Act, as amended, authorize us to collect
this information. We will use the information you provide to accurately identify your Social Security earnings
records, extract the recorded earnings history and to produce the requested statement.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information
may prevent the issuance of a Social Security account statement.
We rarely use the information you supply us for any purpose other than to identify your Social Security
earnings records and issue a Social Security account statement. We 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 agency to assist us 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 and 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
and improvement of our programs (e.g., to the Bureau of the Census and to private entities under
contract with us).
We also may use the information you give us in computer matching programs. Matching programs compare
our records with records kept by other Federal, State and 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 benefits or delinquent debts under these programs.
A complete list of routine uses of the information you provided us is available in our Systems of Records
Notice entitled, Earnings Recording and Self-Employment Income System, Social Security Administration,
Office of Systems, 60-0059. This notice, additional information regarding this form, and information
regarding our programs and systems, are available online at www.socialsecurity.gov
or at your local Social
Security office.
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 (04-2013) EF (04-2013)
Paperwork Reduction Act Notice