Request For Social Security Statement


Request for Social Security
About The Privacy Act
Social Security is allowed to collect the
facts on this form under section 205 of the
Social Security Act. We need them to
Within four to six weeks after you return
quickly identify your record and prepare
this form, we will send you:
the Statement you asked us for. Giving us
• a record of your earnings history;
these facts is voluntary. However, without
• an estimate of how much you have paid
them we may not be able to give you a
in Social Security taxes; and
• estimates of benefits you (and your
Statement. Neither the Social Security
family) may be eligible for now and in
Administration nor its contractor will use
the future.
the information for any other purpose.
Please note: If you have been receiving a
Mail completed form to:
Social Security Statement each year about
Social Security Administration
three months before your birthday, this
Wilkes Barre Data Operations Center
request will stop your next scheduled
Paperwork Reduction Act Notice
mailing. You will not receive a scheduled
PO Box 7004
This information collection meets the requirements of
Statement until the following year.
Wilkes Barre, PA 18767-7004
44 U. S. C. §3507, as amended by Section 2 of the
Paperwork Reduction Act of 1995. You do not need to
We hope you will find the Statement useful
in planning your financial future. Remember,
answer these questions unless we display a valid
Social Security is more than a program for
Office of Management and Budget control number.
retired people. It helps people of all ages in
We estimate that it will take about 5 minutes to read the
many ways. For example, it can help
instructions, gather the facts, and answer the questions.
support your family in the event of your
You may send comments on our time estimate above to:
death and pay you benefits if you become
SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.
severely disabled.
Send only comments relating to our time estimate to
this address, not the completed form.
If you have questions about Social Security
or this form, please call our toll-free
number, 1-800-772-1213.


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