Form Ssa-7050-F4 - Request For Social Security Earnings Information Page 2
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6Form SSA-7050-F4 (10-2016) UF
Page 2 of 4
REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION
1. Provide your name as it appears on your most recent Social Security card or the name of the individual whose
earnings you are requesting.
First Name:
Middle Initial:
Last Name:
-
-
One SSN per request
Social Security Number (SSN)
/
/
/
/
Date of Birth:
Date of Death:
Other Name(s) Used
(Include Maiden Name)
2. What kind of earnings information do you need?
(Choose ONE of the following types of earnings or SSA must return this request.)
Itemized Statement of Earnings $115
Year(s) Requested:
to
(Includes the names and addresses of employers)
to
Year(s) Requested:
If you check this box, tell us why you need this information below.
Check this box if you want the earnings information
Evaluation of a claim
CERTIFIED for an additional $33.00 fee.
Certified Yearly Totals of Earnings $33
Year(s) Requested:
to
(Does not include the names and addresses of employers)
Year(s) Requested:
to
Yearly earnings totals are FREE to the public if you do not
require certification. To obtain FREE yearly totals of earnings,
visit our website at
3. If you would like this information sent to someone else, please fill in the information below.
I authorize the Social Security Administration to release the earnings information to:
c/o Mobile Copy Service
Name
P.O. Box 1250
CA
Address
State
Shingle Springs
95682
City
ZIP Code
4. I am the individual to whom the record pertains (or a person 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.
Signature AND Printed Name of Individual or Legal Guardian
SSA must receive this form within 120 days from the date signed
/
/
Date
Relationship (if applicable, you must attach proof)
Daytime Phone:
Address
State
City
ZIP Code
Witnesses must sign this form ONLY if the above signature is by marked (X). If signed by mark (X), two witnesses to the signing who
know the signee must sign below and provide their full addresses. Please print the signee's name next to the mark (X) on the signature
line above.
1. Signature of Witness
2. Signature of Witness
Address
Address
(Number and Street, City, State and ZIP Code)
(Number and Street, City, State and ZIP Code)
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