Request For Social Security Earnings Information
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1REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION
1. From whose record do you need the earnings information?
Print the Name, Social Security Number (SSN), and date of birth below.
Social Security
Name
Number
Other Name(s) Used
Date of Birth
(Include Maiden Name)
(Mo/Day/Yr)
2. What kind of information do you need?
Detailed Earnings Information
For the period(s)/year(s):
(If you check this block, tell us below
why you need this information.)
Certified Total Earnings For Each Year.
For the year(s):
(Check this box only if you want the information
certified. Otherwise, call 1-800-772-1213 to
request Form SSA-7004, Request for Earnings
and Benefit Estimate Statement)
3. If you owe us a fee for this detailed earnings information, enter the amount due
using the chart on page 3
A. $
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Do you want us to certify the information?
Yes
No
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If yes, enter $15.00
B. $
.
ADD the amounts on lines A and B, and
enter the TOTAL amount
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C. $
• You can pay by CREDIT CARD by completing and returning the form on page 4, or
• Send your CHECK or MONEY ORDER for the amount on line C with the request
and make check or money order payble to "Social Security Administration"
• DO NOT SEND CASH.
4. I am the individual to whom the record pertains (or a person who is 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.
SIGN your name here
(Do not print) >
Date
Daytime Phone Number
(Area Code) (Telephone Number)
5. Tell us where you want the information sent. (Please print)
Name
Address
City, State & Zip Code
6. Mail Completed Form(s) To:
Exception: If using private contractor (e.g., FedEx) to mail form(s), use:
Social Security Administration
Social Security Administration
Division of Earnings Record Operations
Division of Earnings Record Operations
P.O. Box 33003
300 N. Greene St.
Baltimore Maryland 21290-3003
Baltimore Maryland 21290-0300
Form SSA-7050-F4 (01-2004) EF (09-2008)
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