Request For Social Security Statement Page 2
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1
2SOCIAL SECURITY ADMINISTRATION
Request for Social Security
About The Privacy Act Social Security is allowed to
collect the facts on this form under section 205 of the
Statement
Social Security Act. We need them to quickly identify
your record and prepare the statement you asked us for.
Thank you for requesting this statement.
Giving us these facts is voluntary. However, without
them we may not be able to give you a statement.
After you complete and return this form, we will --
Neither the Social Security Administration nor its
within 4 to 6 weeks -- send you:
contractor will use the information for any other
• a record of your earnings history and an
purpose.
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.
We're pleased to furnish you with this information and
we hope you'll find it useful in planning your financial
Paperwork Reduction Act Notice and Time It Takes
future.
Statement
The Paperwork Reduction Act of 1995 requires us to
Social Security is more than just a program for retired
notify you that this information collection is in
Mail completed form to:
people. It helps people of all ages in many ways. Whether
accordance with the clearance requirements of section
Social Security Administration
you're young or old, male or female, single or married --
3507 of the Paperwork Reduction Act of 1995. We may
Wilkes Barre Data Operations Center
Social Security can help you when you need it most. It
not conduct or sponsor, and you are not required to
P.O. Box 7004
can help support your family in the event of your death
respond to, a collection of information unless it displays
Wilkes Barre, PA 18767-7004
and pay you benefits if you become severely disabled.
a valid OMB control number. We estimate that it will
take about 5 minutes to complete this form. This
includes the time it will take to read the instructions,
If you have questions about Social Security or this form,
gather the necessary facts and fill out the form.
please call our toll-free number, 1-800-772-1213.
Authorized Agent:
Knox Attorney Service, Inc.,
Knox Services LLC.
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