Request For Social Security Statement Page 2
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1
2Form Approved
SP
OMB No. 0960-0446
Request for Social Security Statement
Please check this box if you want to get your
For items 6 and 8 show only earnings covered by
9. Do you want us to send the Statement:
Social Security. Do NOT include wages from state,
• To you? Enter your name and mailing
Statement in Spanish instead of English.
local or federal government employment that are
address.
NOT covered by Social Security or that are covered
• To someone else (your accountant, pension
Please print or type your answers. When you have
ONLY by Medicare.
plan, etc.)? Enter your name with “c/o” and
completed the form, fold it and mail it to us. If you
the name and address of that person or
prefer to send your request using the Internet, contact
6. Show your actual earnings (wages and/or net
organization.
us at
self-employment income) for last year and your
estimated earnings for this year.
1. Name shown on your Social Security card:
“C/O” or Street Address (Include Apt. No., P.O. Box, Rural Route)
A. Last year’s actual earnings: (Dollars Only)
,
.
$
0 0
Street Address
First Name
Middle Initial
B. This year’s estimated earnings: (Dollars Only)
Street Address (If Foreign Address, enter City, Province, Postal Code)
,
.
$
0 0
Last Name Only
U.S. City, State, ZIP code (If Foreign Address, enter Name of Country only)
2. Your Social Security number as shown on your
7. Show the age at which you plan to stop working:
card:
NOTICE:
(Show only one age)
I am asking for information about my own
Social Security record or the record of a person
8. Below, show the average yearly amount (not your
I am authorized to represent. I declare under
total future lifetime earnings) that you think you
3. Your date of birth (Mo.-Day-Yr.)
penalty of perjury that I have examined all the
will earn between now and when you plan to stop
information on this form, and on any
working. Include performance or scheduled pay
accompanying statements or forms, and it is
increases or bonuses, but not cost-of-living increases.
true and correct to the best of my knowledge.
If you expect to earn significantly more or less in
I authorize you to use a contractor to send the
4. Other Social Security numbers you have used:
the future due to promotions, job changes, part-
Social Security Statement to the person and
time work, or an absence from the work force,
address in item 9.
enter the amount that most closely reflects your
future average yearly earnings.
If you don’t expect any significant changes,
Please sign your name (Do Not Print)
show the same amount you are earning now
(the amount in 6B).
5. Your Sex:
Male
Female
Future average yearly earings: (Dollars Only)
Date
(Area Code) Daytime Telephone No.
,
.
$
0 0
Form SSA-7004-SM (10-2006) EF (10-2006)
Printed on recycled paper
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