OMB No. 0960-0466
Request for Social Security Statement
Please check this box if you want
9. Do you want us to send the statement:
For items 6 and 8 show only earnings covered
• To you? Enter your name and mailing
to get your statement in Spanish
by Social Security. Do NOT include wages from
instead of English.
State, local or Federal Government employment
• To someone else (your accountant,
that are NOT covered for Social Security or that
pension plan, etc.)? Enter your name with
are covered ONLY by Medicare.
Please print or type your answers. When you
''c/o'' and the name and address of that
have completed the form, fold it and mail it to us.
person or organization.
6. Show your actual earnings (wages and/or net
(If you prefer to send your request using the
self-employment income) for last year and
Internet, contact us at )
your estimated earnings for this year.
''C/O'' or Street Address (Include Apt. No., P.O. Box, Rural Route)
A. Last year's actual earnings: (Dollars Only)
1. Name shown on your Social Security card:
B. This year's estimated earnings: (Dollars Only)
Street Address (If Foreign Address, enter City, Province, Postal Code)
U.S. City, State, Zip code (If Foreign Address, enter Name of Country)
Last Name Only
7. Show the age at which you plan to stop
2. Your Social Security number as shown on
(Show only one age)
I am asking for information about my own Social
8. Below, show the average yearly amount (not
Security record or the record of a person I am
your total future lifetime earnings) that you
authorized to represent. I understand that if I
think you will earn between now and when
deliberately request information under false
3. Your date of birth (Mo.-Day-Yr.)
you plan to stop working. Include
pretenses, I may be guilty of a Federal crime and
performance or scheduled pay increases or
could be fined and/or imprisoned. I authorize you
bonuses, but not cost-of-living increases.
to use a contractor to send the Social Security
Statement to the person and address in item 9.
If you expect to earn significantly more or less
4. Other Social Security numbers you have used:
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
Please sign your name (Do Not Print)
(the amount in 6B).
5. Your Sex:
Future average yearly earnings: (Dollars Only)
Daytime Telephone No.
Form SSA-7004-SM (6-2002) EF (08-20
02Destroy prior editions
Knox Attorney Service, Inc., Knox Services LLC.