Fillable Form SSA-7004 (11-2017): Request for Social Security Statement (U.S. Social Security Administration)

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Form SSA-7004 (11-2017): Request for Social Security Statement (U.S. Social Security Administration)

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The Form SSA-7004 (11-2017): Request for Social Security Statement (U.S. Social Security Administration) form is 3 pages long and contains:

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  • 29 other fields

Country of origin: US
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Form SSA-7004 (11-2017)
Discontinue Prior Editions
Social Security Administration
Page 1 of 3
OMB No. 0960-0466
Request for Social Security Statement
Within four to six weeks after you return this form, we will send you:
• a record of your earning 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.
Please note: If you have received periodic Social Security Statements in the mail, this request may stop your
next scheduled mailing.
We hope you will find the Statement useful in planning your financial future. Remember, Social Security is more than
a program for retired people. Social Security is with you throughout life's journey. For example, it can help support
your family when you die and pay you benefits if you become severely disabled.
If you have 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 Direct 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
/ /
4. Other Social Security numbers you have used:
- -
- -
5. Your Sex:
Male Female
Form SSA-7004 (11-2017) Page 2 of 3
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.
A. Last year's actual earnings: $ (Dollars Only)
.
0 0
B. This year's estimated earnings: $ (Dollars Only)
.
0 0
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: $ (Dollars Only)
.
00
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 on 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.
Please sign your name (Do Not Print)
(Area Code) Daytime Telephone Number
Date
Form SSA-7004 (11-2017) Page 3 of 3
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 60-0224, 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.
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.
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Form SSA-7004 (11-2017): Request for Social Security Statement (U.S. Social Security Administration)

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Completed 25 October 2020

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