Form Ssa-7050-F4 - Request For Social Security Earnings Information Page 4
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6Form SSA-7050-F4 (10-2016) UF
Page 4 of 4
REQUEST FOR SOCIAL SECURITY EARNINGS INFORMATION
Where do I send my complete request?
•
Mail the completed form, supporting documentation,
If using private contractor such as FedEx mail form,
and applicable fee to:
supporting documentation and applicable fee to:
Social Security Administration
Social Security Administration
Division of Earnings and Business Services
Division of Earnings and Business Services
P.O. Box 33011
6100 Wabash Ave.
Baltimore, Maryland 21290-3003
Baltimore, Maryland 21215
How much do I have to pay for an Itemized Statement of Earnings?
•
Non-Certified Itemized Statement of Earnings
Certified Itemized Statement of Earnings
$115.00
$148.00
• How much do I have to pay for Certified Yearly Totals of Earnings?
Certified yearly totals of earnings cost $33.00. You may obtain non-certified yearly totals FREE of charge at
Certification is usually not necessary unless you are specifically asked to obtain
a certified earnings record.
YOU CAN MAKE YOUR PAYMENT BY CREDIT CARD
As a convenience, we offer you the option to make your payment by credit card. However, regular credit card rules will
apply. You may also pay by check or money order. Make check payable to Social Security Administration.
Visa
American Express
CHECK ONE
MasterCard
Discover
Credit Card Holder's Name
(Enter the name from the credit card)
First Name, Middle Initial, Last Name
Number & Street
Credit Card Holder's Address
City, State, & ZIP Code
(
)
-
Daytime Telephone Number
Area Code
Credit Card Number
-
-
-
Credit Card Expiration Date
(MM/YY)
Amount Charged
$
See above to select the correct fee for your request.
Applicable fees are $33, $115, or $148
SSA will return forms without the appropriate fee.
Credit Card Holder's Signature
Authorization
DO NOT WRITE IN THIS SPACE
Date
Name
OFFICE USE ONLY
Remittance Control #
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