Fillable SSA-7050 Request for Social Security Earnings Information

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SSA-7050 Request for Social Security Earnings Information

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Form SSA-7050-F4 (03-2019)
Discontinue Prior Editions
Social Security Administration
Page 1 of 4
OMB No. 0960-0525
REQUEST FOR SOCIAL SECURITY EARNING 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.
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 TO REQUEST
YEARLY EARNINGS TOTALS
Yearly earnings totals are free to the public
if you do not require certification.
To obtain FREE yearly totals of earnings,
visit our website at www.ssa.gov/myaccount.
Privacy Act Statement
Collection and Use of Personal Information
Section 205 of the Social Security Act, as amended, authorizes us to collect the information on this form. We will use the
information you provide to identify your records and send the earnings information you request. Completion of this form is
voluntary; however, failure to do so may prevent your request from being processed.
We rarely use the information in your earnings record for any purpose other than for determining your entitlement to
Social Security benefits. However, we may use it for the administration and integrity of Social Security programs. We may
also 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 an agency to assist Social Security in establishing rights to Social Security benefits
and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security 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 Social Security programs.
A complete list of routine uses for earnings information is available in our Systems of Records Notices entitled, the
Earnings Recording and Self-Employment Income System (60-0059), the Master Beneficiary Record (60-0090), and the
SSA-Initiated Personal Earnings and Benefit Estimate Statement (60-0224). In addition, you may choose to pay for the
earnings information you requested with a credit card. 31 C.F.R. Part 206 specifically authorizes us to collect credit card
information. The information you provide about your credit card is voluntary. Providing payment information is only
necessary if you are making payment by credit card. You do not need to fill out the credit card information 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 the Social Security
Administration's (SSA) account.
Routine uses applicable to credit card information, include but are not limited to: (1) to enable a third party or an agency
to assist Social Security to effect a salary or an administrative offset or to an agent of SSA that is a consumer reporting
agency for preparation of a commercial credit report in accordance with 31 U.S.C. §§ 3711, 3717, and 3718; and (2) to a
consumer reporting agency or debt collection agent to aid in the collection of outstanding debts to the Federal
Government. A complete list of routine uses for credit card information is available in our System of Records Notice
entitled, the Financial Transactions of SSA Accounting and Finance Offices (60-0231). The notice, additional information
regarding this form, routine uses of information, and our programs and systems is 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 11 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.
Form SSA-7050-F4 (03-2019)
Page 2 of 4
REQUEST FOR SOCIAL SECURITY EARNING INFORMATION
1. Provide your name as it appears on your most recent Social Security card or the name of the individual whose
earnings you are requesting.
First Name: Middle Initial:
Last Name:
Social Security Number (SSN)
One SSN per request
Date of Birth: Date of Death:
Other Name(s) Used
Maiden Name)
2. What kind of earnings information do you need? (Choose ONE of the following types of earnings or SSA must return
this request.)
Itemized Statement of Earnings $91.00
(Includes the names and addresses of employers)
If you check this box, tell us why you need this
information below.
Year(s) Requested:
to
Year(s) Requested:
to
Check this box if you want the earnings
information CERTIFIED for an additional
$34.00 fee.
Certified Yearly Totals of Earnings $34.00
(Does not include the names and addresses of
employers)Yearly earnings totals are FREE to the public if you
do not require certification. To obtain FREE yearly totals of
earnings, visit our website at www.ssa.gov/myaccount
.
Year(s) Requested:
to
Year(s) Requested:
to
3. If you would like this information sent to someone else, please fill in the information below.
I authorize the Social Security Administration to release the earnings information to:
Name
Address State
City ZIP Code
4. I am the individual to whom the record pertains (or a person 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.
Signature AND Printed Name of Individual or Legal Guardian
SSA must receive this form within 120 days from
the date signed
Date
Relationship (if applicable, you must attach proof) Daytime Phone:
Address State
City ZIP Code
Witnesses must sign this form ONLY if the above signature is by marked (X). If signed by mark (X), two witnesses to the
signing who know the signee must sign below and provide their full addresses. Please print the signee's name next to the
mark (X) on the signature line above.
1. Signature of Witness
Address (Number and Street, City, State and ZIP Code)
2. Signature of Witness
Address (Number and Street, City, State and ZIP Code)
Form SSA-7050-F4 (03-2019)
Page 3 of 4
REQUEST FOR SOCIAL SECURITY EARNING INFORMATION
INFORMATION ABOUT YOUR REQUEST
You may use this form to request earnings information for one ONE Social Security Number (SSN)
How do I get my earnings statement?
You must complete the attached form. Tell us the
specific years of earnings you want, type of earnings
record, and provide your mailing address. The itemized
statement of earnings will be mailed to ONE address,
therefore, if you want the statement sent to someone
other than yourself, provide their address in section 3.
Mail the completed form to SSA within 120 days of
signature. If you sign with an "X", your mark must be
witnessed by two impartial persons who must provide
their name and address in the spaces provided.
Select ONE type of earnings statement and include the
appropriate fee.
1. Certified/Non-Certified Itemized Statement of
Earnings
This statement includes years of self-employment or
employment and the names and addresses of
employers.
2. Certified Yearly Totals of Earnings
This statement includes the total earnings for each
year requested but does not include the names and
addresses of employers.
If you require one of each type of earnings statement,
you must complete two separate forms. Mail each form
to SSA with one form of payment attached to each
request.
How do I get someone else's earnings
statement?
You may get someone else's earnings information if you
meet one of the following criteria, attach the necessary
documents to show your entitlement to the earnings
information and include the appropriate fee.
1. Someone Else's Earnings
The natural or adoptive parent or legal guardian of a
minor child, or the legal guardian of a legally
declared incompetent individual, may obtain
earnings information if acting in the best interest of
the minor child or incompetent individual. You must
include proof of your relationship to the individual
with your request. The proof may include a birth
certificate, court order, adoption decree, or other
legally binding document.
2. 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 (e.g.,
financial) who is an heir at law, next of kin,
beneficiary under the will or donee of property of
the decedent.
You must include proof of death and proof of your
relationship to the deceased with your request.
Is There A Fee For Earnings Information?
Yes. We charge a $91.00 fee for providing information
for purposes unrelated to the administration of our
programs.
1. Certified or Non-Certified Itemized Statement of
Earnings
In most instances, individuals request Itemized
Statements of Earnings for purposes unrelated to
our programs such as a private pension plan or
personal injury suit. Bulk submitters may email
OCO.Pension.Fund@ssa.gov
for an alternate
method of obtaining itemized earnings information.
We will certify the itemized earnings information for
an additional $34.00 fee. Certification is usually not
necessary unless you are specifically requested to
obtain a certified earnings record.
Sometimes, there is no charge for itemized earnings
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 year(s) in
question. 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.
2. Certified Yearly Totals of Earnings
We charge $34.00 to certify yearly totals of
earnings. However, if you do not want or need
certification, you may obtain yearly totals FREE of
charge at www.ssa.gov/myaccount. Certification is
usually not necessary unless you are advised
specifically to obtain a certified earnings record.
Method of Payment
This Fee Is Not Refundable. DO NOT SEND CASH.
You may pay by credit card, check or money order.
• Credit Card Instructions
Complete the credit card section on page 4 and
return it with your request form.
• Check or Money Order Instructions
Enclose one check or money order per request
form payable to the Social Security
Administration and write the Social Security
number in the memo.
How long will it take SSA to process my request?
Please allow SSA 120 days to process this request.
After 120 days, you may contact 1-800-772-1213 to
leave an inquiry regarding your request.
Form SSA-7050-F4 (03-2019)
Page 4 of 4
REQUEST FOR SOCIAL SECURITY EARNING INFORMATION
• Where do I send my complete request?
Mail the completed form, supporting documentation,
and applicable fee to:
Social Security Administration
P.O. Box 33011
Baltimore, Maryland 21290-33011
If using private contractor such as FedEx mail form,
supporting documentation, and application fee to:
Social Security Administration
P.O. Box 33011
Baltimore, Maryland 21290-33011
• How much do I have to pay for an Itemized Statement of Earnings?
Non-Certified Itemized Statement of Earnings
$91.00
Certified Itemized Statement of Earnings
$125.00
• How much do I have to pay for Certified Yearly Totals of Earnings?
Certified yearly totals of earnings cost $34.00. You may obtain non-certified yearly totals FREE of charge at
www.ssa.gov/myaccount. Certification is usually not necessary unless you are specifically asked to obtain a
certified earnings record.
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 also pay by check or money order. Make check payable to Social Security Administration.
CHECK ONE
Visa American Express
MasterCard Discover
Credit Card Holder's Name
(Enter the name from the credit card)
First Name, Middle Initial, Last Name
Credit Card Holder's Address
Number & Street
City, State, & ZIP Code
Daytime Telephone Number
Area Code
Credit Card Number
Credit Card Expiration Date
(MM/YY)
Amount Charged
See above to select the correct fee for your request.
Applicable fees are $34.00, $91.00, or $125.00.
SSA will return forms without the appropriate fee.
$
Credit Card Holder's Signature
Date
DO NOT WRITE IN THIS SPACE
OFFICE USE ONLY
Authorization
Name
Date
Remittance Control #
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SSA-7050 Request for Social Security Earnings Information

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Completed 6 May 2020

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