Worksheet Of Purchase Of Retirement Credit For Philadelphia Service
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440 North Broad Street, Suite G-8
PHILADELPHIA, PENNSYLVANIA 19130-4015
TELEPHONE (215) 400-4680
FAX: 215-400-4681
WORKSHEET OF PURCHASE OF RETIREMENT CREDIT FOR PHILADELPHIA SERVICE ONLY
This Worksheet is to be used for the purchase of prior unaccredited service toward retirement credit. Enter as much
information as possible and return it to the address given above.
CURRENT
OTHER NAMES OR SS# USED
Name _________________________________________
__ ___________________________
SS # _______________________________________________
_________________________________
Address ____________________________________________
City, State, Zip Code __________________________________
Phone # ___(_______)_________________________________
FOR ALL YEARS REQUESTED BEFORE THE YEAR 1970
If you do not have pay stubs to send with this information, then please write to Social Security for Form SSA-7050-F4 at the following
address:
Social Security Administration, Division of Earnings Record Operations, P.O. Box 33003, Baltimore, Maryland 21290-3003
BEFORE 1970
Type of Service
Dates Claimed
Name of School or Work
(Per Diem, Hourly,
Job Title
FROM
TO
Location
Full Time, Part Time
month/yr
month/yr
Social Security will charge you for this information
AFTER 1970
Form SSA-7050-F4 not required. Fill in the needed information only.
Type of Service
Dates Claimed
Name of School or Work
(Per Diem, Hourly,
Job Title
FROM
TO
Location
Full Time, Part Time
month/yr
month/yr
I certify that I have not received credit for this service in any other retirement system.
__________________________________________________
_______________________________________
Signature of Applicant
Date
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